Republic of the Philippines

EASTERN VISAYAS STATE UNIVERSITY

Tacloban City

MEDICAL CERTIFICATE
Date:_________________

This is to certify that, ________________________________________, ___ years old from EASTERN VISAYAS STATE
UNIVERSITY- TACLOBAN CITY came in to this clinic on _____________________________ for

( ) Physical Examination ( ) Treatment as out-patient

IMPRESSION/ DIAGNOSIS:

REMARKS/DISPOSITION: ( ) Physically and mentally fit / unit

( ) Advised continuous treatment at home and regular check-up
( ) Advised rest for ________________ days/ weeks/ months

MA. SALUD N. ROSILLO, M.D

Medical Officer lll
License No. 82635
PTR No.