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Kingdom of Sandia Arabia F- eee) I) wea AL-TAKHSEES MEDICAL GROUP I ¢ Abii ppunsill A 7 Lic, No. 065-001-22-10-10004 fears, 0730 teens Patient Name : Medical Record No ™ a Nationalatiy : on Date Of BIPth © een ‘Occupation : Place of work :. Date of ‘Adm Date: Discharge Date Recommendation Ty say Following Medical examination. itis recommended Pt gua dy Nolo oy sick Leave for uunn-- dayls AL AR pa gpn (APS Woke pSSbp onde] Starting From To LET (HK sebbcctatllinse( dhads |r ottow up before end of sick leave ASiLapfelgit J gia att ae tpe J] \CReferral to Medical Commite forfollowing reasons : AMEN Ao St Aalall Ayatadl Aad oN Azim] approval os sick leave = ggdall pat alezet J) cannot be treated at this Fact a fp pa (oe seeene cetyl Satna ol] Cpermanet or Partial disability * = Pyatil sD ip Bygues Seal Ge grullojne le JS Atti] Others : ‘Treating Physical Name: Signature Approvead by the Director of : Name Signature : Date: sat aff stot sate 11 La} 1 al el eat ce ela Rate Ly dele AS odlal dea) east pS Labs Baste GH BLA ssp yaleatt pepaitl Atlas pied oes oe

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