R.A.

10172
REPUBLIC OF THE PHILIPPINES
PROVINCE OF: ______________________
CITY/MUNICIPALITY OF: ______________________

M E D I C A L C E R T I F I CA T I O N

Name:
Date of Birth:
Place of Birth:

Medical statements:

That I have examined the above named person and that after examining the same person, I certify
that he/she has not undergone sex change or sex transplant.

Signature over printed name of the Physician

Medical License No.

Date:

RA 10172
REPUBLIC OF THE PHILIPPINES
PROVINCE OF: ______________________
CITY/MUNICIPALITY OF: ______________________

C E R T I F IC A T E O F A U T H E N T I C I T Y

I, _____________________________, the City / Municipal Civil Registrar of

(name of C/MCR) (city/municipality)

_____________________, certify that _____________________________________with

(name of accredited government physician) (medical license no.)

_______________________is an accredited government physician appointed/designated/assigned as

(position)

______________________________________ at __________________________________ and that we

(place)

have verified that he/she has examined the petitioner

(name) (date of birth) (place of birth)

bbbbbbbb
_________________________________________,___________________,

____________________ and that the certification issued by the above-named physician is genuine and

authentic.
______________________________
Signature over printed name of C/MCR

Date: ___________________________