CSC Form No.

41
PHILIPPINE CIVIL SERVICE
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
questions containing herein.

_________________________________________
(Patient’s Signature Over Printed Name)

______________________________________________________________________________

N.B. Attending Physician should fill in the blanks below. Every detail should be
answered to avoid delay in action on application for leave submitted by the patient:
_____________________________________ of the Department of Education. Having made
(Name of Patient)
application for leave of absence on ______________________________, I do hereby certify that
I was the applicant’s attending physician from ________________ to ______________ 20____
inclusive and from professional knowledge of the case following statement are submitted, as
contemplated by provision of Section 7 of Civil Service Rule XV.

Name of Disease or Disability: ____________________________________________________

Nature of Disease or Disability: ____________________________________________________
______________________________________________________________________________

Under this heading, in addition to giving fully the Ratio Log of RETOLOG. The disease
of disability the physician must either state in the language of the Executive Order, here there
are no indications whatever the disease named was due to immoral or vicious habits or give
indications.
______________________________________________________________________________

______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________

HISTORY:
______________________________________________________________________________
______________________________________________________________________________
Description:____________________________________________________________________
Laboratory test or examination was _________________________________________________
made in this case. The applicant was confined to his home from_______________________ to
_______________________ 20____ inclusive.

I HEREBY CERTIFY that the statement are completed and true to every detail and not in
consequence of the diseases or the disability above the applicant was all and unable to be account
of illness from _____________________ to ________________________ inclusive, and that
his/her claim is meritorious.

_______________________________________
(Signature of Physician over Printed Name)

_______________________________________
(Address)
Attach Documentary Stamp
_______________________________________
(Date)