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    Medical Certificate: C.S. FORM No. 41

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    adoriza0218
    The document is a medical certificate completed by a physician to certify a patient's leave of absence from work due to illness. It requests details of the patient's disease or disability, history, description, any laboratory tests, dates of confinement, and a statement that the physician's claim is meritorious. The physician is authorized to disclose full medical details to avoid delayed processing of the patient's leave application.

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    Medical Certificate: C.S. FORM No. 41

    Uploaded by

    adoriza0218
    135 views1 page
    The document is a medical certificate completed by a physician to certify a patient's leave of absence from work due to illness. It requests details of the patient's disease or disability, history, description, any laboratory tests, dates of confinement, and a statement that the physician's claim is meritorious. The physician is authorized to disclose full medical details to avoid delayed processing of the patient's leave application.

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    Original Title

    Medical Certificate

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    The document is a medical certificate completed by a physician to certify a patient's leave of absence from work due to illness. It requests details of the patient's disease or disability, history, description, any laboratory tests, dates of confinement, and a statement that the physician's claim is meritorious. The physician is authorized to disclose full medical details to avoid delayed processing of the patient's leave application.

    Copyright:

    © All Rights Reserved
    Download as DOC, PDF, TXT or read online from Scribd
    Download as doc, pdf, or txt
    135 views1 page

    Medical Certificate: C.S. FORM No. 41

    Uploaded by

    adoriza0218
    The document is a medical certificate completed by a physician to certify a patient's leave of absence from work due to illness. It requests details of the patient's disease or disability, history, description, any laboratory tests, dates of confinement, and a statement that the physician's claim is meritorious. The physician is authorized to disclose full medical details to avoid delayed processing of the patient's leave application.

    Copyright:

    © All Rights Reserved
    Download as DOC, PDF, TXT or read online from Scribd
    Download as doc, pdf, or txt
    of 1

    C.S. FORM No.

    41

    MEDICAL CERTIFICATE

    I HEREBY WAIVE all rights and privileges pertaining to professional confidence


    between physician and patient, and the physician accomplishing this form is authorized to
    answer in detail all questions contained herein.

    ____________________________
    (Signature of Patient)

    (NB) Attending physician should fill in the blanks below. Every detail should be
    answered to avoid delayed action on application on for leave.
    ___________________________, of the Department of Education.
    (Name of Patient)
    Having made application for leave of absence on account of illness, I do hereby certify
    that I was the applicant’s actual attending physician from ___________ to ___________
    inclusive and from my professional knowledge of the case of the following statements are
    submitted as contemplated by the provision of section 8 of Civil Service Rule XI.
    Name of disease or disability __________________________________________
    Nature of disease or disability _________________________________________
    __________________________________________________________________
    (Under this heading, in addition to giving fully the etiology of the disease of
    disability, the physician must either state in the language of the Etiology)
    (Executive Order: there are no indications whatever that disease named was due
    to immoral or vicious habit or give the indication.
    History _________________________________________________________________
    __________________________________________________________________
    Description _____________________________________________________________
    __________________________________________________________________
    Laboratory test or examination was ____________ made in this case. The applicant was
    confined to his/her house/hospital ____________________________ from ___________
    ____________________ inclusive and that his/her claim is meritorious.

    ____________________________
    (Signature of Physician)

    ____________________________
    Post Office Address

    ____________________________
    Date

    Jsm031412

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