NOTRE DAME OF MARBEL UNIVERSITY

Alunan Avenue, Koronadal City, South Cotabato 9506

UNIVERSITY CLINIC

CERTIFICATE OF CONSULTATION

To whom it may concern:

This is to certify that according to our records,
(NAME)
years old, with the residence at
(AGE) (ADDRESS)
was examined and treated on .
(DATE)

Remarks:

Signature over Printed Name of Physician

License No.

NDMU-UCVH-0006

NOTRE DAME OF MARBEL UNIVERSITY

Alunan Avenue, Koronadal City, South Cotabato 9506

UNIVERSITY CLINIC

WAIVER FORM

To Whom It May Concern:

I refuse to
I hereby free Notre Dame of Marbel University of any responsibility which might arise from any

refusal to be treated/ referred by the School Physician at the Notre Dame of Marbel University clinic.

Name and Signature

NDMU-UCWF-0005