DTS Number

Health Services Office

MEDICAL CERTIFICATE REQUEST FORM

Requesting Office:____________________ Person In-Charge:_______________________

Purpose: ___________________________ (Signature over Printed Name)
Date of Activity:______________________ Endorsed by:___________________________
Address of Activity:___________________ (Signature over Printed Name)

2401 Taft Avenue, 0922 Manila, Philippines I Tel: (632) 536-0252 | Trunk Line: (632) 524-4611 loc. 221
clinic@dlsu.edu.ph I www.dlsu.edu.ph
 DTS Number

Health Services Office

Designation: a. Faculty Adviser

Contact no./Email:____________________ (Encircle) b. Head of Office
c. Immediate Superior

LIST OF PARTICIPANTS

ID Number Name Gender Birthday Age

(Family, First, Middle)
DO NOT WRITE NICKNAME

2401 Taft Avenue, 0922 Manila, Philippines I Tel: (632) 536-0252 | Trunk Line: (632) 524-4611 loc. 221
clinic@dlsu.edu.ph I www.dlsu.edu.ph
 DTS Number

Health Services Office

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2401 Taft Avenue, 0922 Manila, Philippines I Tel: (632) 536-0252 | Trunk Line: (632) 524-4611 loc. 221
clinic@dlsu.edu.ph I www.dlsu.edu.ph
 DTS Number

Health Services Office

10.
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2401 Taft Avenue, 0922 Manila, Philippines I Tel: (632) 536-0252 | Trunk Line: (632) 524-4611 loc. 221
clinic@dlsu.edu.ph I www.dlsu.edu.ph
 DTS Number

Health Services Office

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RECEIVED STAMP RECEIVED STAMP (HSO) PICK UP DATE & ASSIGNED RECEIVED BY
(Concierge) NURSE (To be filled out by requestor after
(To be filled out by HSO staff) received the Medical Certificate request)

Softcopy date received: _____________ Signature Over Printed Name/Date

2401 Taft Avenue, 0922 Manila, Philippines I Tel: (632) 536-0252 | Trunk Line: (632) 524-4611 loc. 221
clinic@dlsu.edu.ph I www.dlsu.edu.ph
 DTS Number

Health Services Office

2401 Taft Avenue, 0922 Manila, Philippines I Tel: (632) 536-0252 | Trunk Line: (632) 524-4611 loc. 221
clinic@dlsu.edu.ph I www.dlsu.edu.ph