HEALTH CERTIFICATE FOR MESSAGE

CLINIC ATTENDANT, RECEPTIONIST,

HOSTESSES, HOSPITALITY GIRLS /
BOYS, ETC.
(PINK COLOR)
EHS FORM NO. 102-A
IMPORTANT
Logo of City/ =============
Municipality THIS HEALTH CERTIFICATE IS NON-
Office of the City /Mun. TRANSFERABLE.
Health Officer ALWAYS WEAR YOUR CERTIFICATE IN
================================ THE UPPER LEFT SIDE FRONT PORTION OF YOUR
Reg. No. GARMENT WHILE WORKING.
VALID ONLY UNTIL THE NEXT DATE OF
EXAMINATION, AS INDICATED BELOW.
HEALTH CERTIFICATE
Pursuant to the provision of P.D. 522, P.D. 856 and City /

Mun. Ord. No. & this Certificate is issued for Date of Issuance Date of Expiration

NAME:
IMMUNIZATION
OCCUPATION:
DATE KIND DATE OF EXP.
AGE: SEX: NATIONALITY

PLACE OF WORK: X-RAY

SIGNATURE DATE KIND RESULT

I.D.
PICTURE STOOL & OTHER EXAM.
1X1 CSD/SE-IN CHARGE

(CHO/MHO)
DATE KIND RESULT

FRONT (14cm. x 9cm)

EHS FORM NO. 102-C

STD EXAMINATION URETRAL/CERVICAL SMEAR EXAM.
DATE OF DATE OF DATE OF DATE OF
RESULT RESULT
E3XAM NEXT EXAM E3XAM NEXT EXAM

HBsAg EXAMINITION
DATE OF DATE OF
RESULT
E3XAM NEXT EXAM

HBsAg EXAMINITION
DATE OF DATE OF
RESULT
E3XAM NEXT EXAM

BACK (14cm. x 9cm)