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Polangui Health Center

Gabon, Polangui, Albay

Date: _____________________

MEDICAL CERTIFICATE

TO WHOM IT MAY CONCERN:


This is to certify that ________________________________, ____________
years old, (male, female), (single, married), residing at
_____________________________ (Confined, Consulted, Treated) in this Health
Center on ________________from ___________ to_____________________ because of
________________________________
______________________________________________________________________________
______________________________________________________________________________
DIAGNOSIS:
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
Remarks/ Recommendation:
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
This certification is issued upon the request of the interested party for
whatever purpose it may serve.

________________________M.D
Attending Physician
LIC. No.______________

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