Republic of the Philippines

Department of Education
REGION X- NORTHERN MINDANAO
DIVISION OF MALAYBALAY CITY
MEDICAL CERTIFICATE

Date:

Patient’s Name: _______________________________Age: ____________ Gender: __________

Address: _______________________________________________________________________

This is to certify that I have personally seen & examined the above mentioned patient because of
_______________________________________________________________________________

Impression: __________________________

This certificate is being issued to the interested party for_________________________________

This is not valid for medico-legal purposes.

_________________________
Attending Physician
Lic. # ______________
PTR. # _____________

Document No. : FM-SCH-02 Eff. Date : 06-07-21

Purok 6, Casisang, Malaybalay City
Telefax (088) 314-0094
Revision No. : 01 Pages : 1 of 1
Email: malaybalay.city@deped.gov.ph