%E-103/Med-109 | etgupt a | Certificate granted to Mrs./Mr/Miss. wifefson/daughter of Mr... employed in the... ww a CERTIFICATE ‘A’ (ot Girt & amet He wre Ret rere & fry reat wf x few ver WD (To be completed in the case of patients wh aro not admitted to hospital for treatment) fe a RT va war ES 5 ee : OpEERRHDNA bod ss shereby cortiy:— Se eae cede aie ace see tree . egouoguGd poe oe RIC waft fire she wer fire (2) that I charged and received Rs. . ae eoconkns ‘consultations on sevedeieenees 1. + hy coneating TooRVa the reskonc ofthe pation (Dates to be given) (Co) fe BY ot wont we rot fre eM we Gt Bow. pe ee CICS dougovouds sqobcadug “re gtr foe abe arr fg | (©) administering coon Intramuscularsub-ctaneous injections on at my consulting roomiat the residence of the pation, (Dates to be given) oo fe fee we thet trea tr Pritt & fq aot a (c) thatthe injections administered weretwere not for immunising or prophylactic purposes. es gk eee + sree FAR wo we A grb ok re eM ea we 78H ob fete ot OE ort dhe we GU A woe Be ted fe ated oh te See src 8 ote Ort Uh rE TH Tt (creer sor a) tomatoe Re Cera) ar et att Peek fine wer fafa wee wa re caw tA a ar Sty we, pre wt oe fiom 1 (6) thatthe pationt has been under treatment at cosceepeneeees - hospteliny consulting room and that the undermentioned medicines prescribed byme in this connection were essential for the recovery/preventions of serious deterioration in the condition f the patient. The medicines are not stocked in the {name of the hospital) . ‘supply to private patients and do not2 @ fe wt. fer tre ste. ne ome . we Rt te (0) that the patient is/was suffering from . iswas under my treatment from we : : Ce) feb wer pe orem ate fairer et nt tet (f) thatthe pationt is/was not given prenatal or post-natal treaiment. Co) Fe Rex et, wa we ER RE 2 wag nd fig 2A rere a ate RAT WR 2 A foc me (oer yee 1) (0) that Xray, laborats test, ote. for which an expenditure of Rs was incured were necessary and were undertaken on my advice at cee eeeetetenteeeeeeee (ram ofthe hospital or aboratory) eR NH fete WOME REM fee ae tor at ok : rn ee Sagme ater saree ater we we fer TT at | (hn) that Heoforod the pstiont 9 Dr. eesseseeeee for specials onsutation and thatthe necessary approvalolthe -ses.0-.. sossssesss sees a8 required under the cules was obtained (name ofthe Chet Acminstatve Mecca Oticor) (fe wt orm A CEM ore A vaRREE at 1 | (thatthe pationt did ot roquirertoquired hospitalisation. | . Se ee ee ee . Foren attend) were ke earn ten eee woe Lee Paferrere ar arr fart ae war tt Dato a Signature & Designation of the Medical Otficor and the HospialDispensary to which alachod. fe ES were aT aa we Rew WE ae Go ated Pat Mee alee Bo a wt wet 1 ee a | _NB8—Certcates aot aplcnba should be struck ot. Ceticte a) is compulsory and must bo filed in by the Metical Oca in al cases | wares —26 UpmaRttflret/94/MGIPK-—24 FSC/Cid 94(204)-7-10-94--95,00,000.