wife/son/danghter of Mr. ___ b) ° da 8 A 8) h) ESSENTIALITY CERTIFICATE FOR OUTDOOR PATIENTS CERTIFICATE 'A' (to be completed in the case of patients who are not admitted to hospital for treatm Certificate granted to Mrs./Mr./Miss “einployed in. the _ hereby certify that 1 charged and received Rs. - for Be consultations on ____. (dates to be given) at my consulting room/at the residence of the patient. that I charged and received Rs. __. tor administering — ee intra muscular/subeutaneous injections on _ (dates to be given) at my consulting room/at the residence of the patient. that the injections administered were/were not for immunising or prophylactic purposes. that the patient has been under treatmenit at ______ hospital/my consullting room y me in this connection were essential. tmedicines Price that the patient is/was suffering from _ under treatment from __ that the patient i s/was not given prenatal or postnatal treatment. that the x-ray, lab tests etc. for which an expenditure of Rs. __ incurred were necessary and were undertaken on my advice at __. (Name of hospital or lab.) that I referred the patient to Dr consultation and that the necessary approval of the (name of the Chief Admn, Medical Officer of the State) a8 require obtained. thet the patient did not require/required hospitalisation. Sign & Designation of the Medical Officer of the Hospital/ Dispensary to which attached ‘ate not applicable should be struck off. Certificate (e) is compulsory and must be filled in by the Medical Officer imal eases,ESSENTIALITY CERTIFICATE FOR INDOOR PATIENTS: CERTIFICATE (to be completed in the case of patients who are admitted to hospital for treatment) Certificate granted to Mrs./Mr,/Miss \te-son/daughter of Mr. “employed in the 1Dr. hereby certify: 4) that the patient was admitted to hospital on the advice of ____ (name of the Medical fficer)/on my advice. D that the poatient has been under treatment at __ ___ and that the under: mentioned medicines prescribed by me in this connection were essential for the recovery/prevention of serious deterioration in the condition of the patient. The medicines are not stocked in the = ________ (name of tne hospital) for supply to private patients and do not include proprietary preparations for which cheaper substances of equal therapeutic value are available nor preparation which are primary foods, toiletries or disinfectants. Name of medicines Price ©) that the injections administered were/were not for immunising or prophylactic purposes. that the patient is/was suffering from __and is/was onder treatment from a ©) that the x-ray 's ete. for which an expenditure of was ‘e necessary and were undertaken on my advice at __ (Name of hospital or lab.) _for specialist consultation and that = — (name of the required under the rules, was obtained. the necessary approval of the nn, Medical Officer of the State) Sign & Designation of the Medical Officer in charge of the case at the hospitalPART 'B I certify that the patient has been under treatment at the hospital and that the service of the ‘an expenditure of was incurred vide bills and receipts attached, were essential for the recovery/prevention of serious deterioration in the condition of the patient. Countersigned Sign & Designation of the Medical Superintendent Medical Officer in charge of the case at the hospital hospital COUNTERSIGNED "I certify thatthe patient has-been under treatment atthe _ hospital and that the facilities were the minimum which were essential for the patient's treatment. Medical Superintendent _____ hospital Place __ Date _ Note: Certificate not applicable should be struck off. Certificate (d) is compulsory and must be filled by the Medical Officer in all cases. +The minimum: of facilities certificate may be si igned either by, the Medical Supdt. obf the hospi concerned or another gazetted Medical Officer who has been authorised in the behalf by the Medica Supdt