Date:

TO WHOMSOEVER IT MAY CONCERN

This is to certify that Mr/Mrs........................................... (aged years) residing at

........................................................................................................................................
.......................................................................................................................................
is suffering from ..................................................... and is under my medical treatment
for the same. He/She needs domiciliary treatment for 3 months/6 months. He/She is
advised to undergo following periodical investigations for monitoring his/her health
condition:

1.
2.
3.

He/She is further advised to take/continue the following medicines for a period of 3

months/6 months. Dosage modification of medicines will be made, if necessary. In
case of any emergency, apart from the medicines mentioned here under, other
necessary medicines will also be prescribed.

Sl. No. Medicine Dosage M A E N B Food A Food

1.
2.
3.
4.
5.

Review: After ....... Months.

SIGNATURE:

NAME OF THE
ATTENDING
DOCTOR:

DESIGNATION:

SEAL WITH REGN. No: