MEDICAL CERTIFICATE

______________________

(Date)

To Whom It May Concern:

This is to certify that ________________________________________ received full doses of

immunization against measles, mumps, and rubella as a child, meeting the childhood immunization

schedule in …………….

This medical certificate is issued per request of the above-name patient.

_____________________________ ____________________________

Name of Health Practitioner Signature of Health

Practitioner

_____________________________ ___________________________

Physician/ Agency Stamp Telephone number