aaa... ‘fefr.-104 Med-104 WaT (et) CERTIFICATE ‘B (ae Ofrat & aeret Ft ger ara fae rer & fee sreveret Fae fever Tea eH) (fo be completed in the case of patients who are admitted to hospital for treatment) Peg stat re. wetegrpt 2. ‘Certificate granted to Mrs./Mr/Miss...... ‘wet S67 PART ‘A? (arrears Fence sified rer we sg FE) (To'be signed by the Medical Officer in- Charge of the case atthe hospital) (@) feat ee fee... Amt ak fe Bese TR rr FRE a St rete aback at at eee a gure ar Herre we’ R TTS ‘et i fre afrard oh 2 ati. : a sorte afteeweftct/COUNTERSIGNED safes aicen & fas at genet & fore. -gfart ng oh & hit cere & fe Prd =O gre certify thatthe patient has been under treatment atthe. facilities provided were the minimum which were essential forthe patient's treatment, Ee Place anes — ait... Date fate oar seers ar a wa ae Re Eg eer a re E ate ae aot oat Heer fer rr TT fe N.B: Certificate not applicable should be struck off. Certificate "Bis compulsory and mist be filled by theMedical Officer in all cases, : ‘LPICT/2052107 da 28-05-07 5000copies Printocraft, Ch-16