MEDICAL SICKNESS CERTIFICATE

Department of Internal Medicine
Fortis Hospital,
Bangalore, Karnataka -342001
No. …… / F.M. / Med. Cert. / 2014 Bangalore
Karnataka.
Dated: -

. . 2014

This is to certify that I ……………………………………………………… have personally examined Shri/ Smt./
Ku. ….…………………………….…….. s/ w/ d/ o …………..……… aged about ……….. years, sex male/
female, …………………….., occupation …….……………., resident of
………………………………………………………………………………… (Whose signature/ left thumb
impression is verified as under). He/she is suffering from (disease)
……………………….……………………………………….. And I have advised him/ her
……………….………………………….…………… . …………………………………………….
I do consider that absence of ……………………………….. days with effect from …………….….….. to
………………… is absolutely necessary for restoration of his/ her good health.
Identification marks of patient:
1.
2.
Signature …….…………………………….
Verified signature Name ……………………….……………….
Qualification ……………………………...
Registration No. ………….……………….
Designation ………………….…………….
Patient Address ……….……….……………………
Date:
Place: ….……………………………………