CS Form 41

PHILIPPINE CIVIL SERVICE

MEDICAL CERTIFICATE

I hereby waive all rights and privileges pertaining to professional confidences

between physician and patient and the physician accomplishing this form authorized to
answer in details all questions contained herein.
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(Signature of Patient)
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(N.B. – Attending physician should fill in the blanks below. Every detail should
be answered to avoid delay in action or application for leave submitted by the patient.)

______________________________________ of the _________________________________ having

(Name of Patient)
made application for leave of absence on account of illness, I do hereby certify that I was the
applicant’s actual attending physician from ____________ 20_______ to_________ 20, _________
inclusive, as contemplated by the provision of section 8 of the Civil Service Rule XVII.

Name of the disease or disability _________________________________________________________

Nature of disease or disability ___________________________________________________________
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(Under this heading, in addition to giving fully the etiology of the disease or ETIOLOGY (disability,
the physician must either state in the language of the Executive order, “There are no indication whatever
that the disease named was due to immoral or vicious habits” or give the indications.)
____________________________________________________________________________________
____________________________________________________________________________________
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History _______________________________________________________________________
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Description _______________________________________________________________________
_______________________________________________________________________
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Laboratory test or examination was _______________ made in the case.
The applicant was confined to (Hospital) from _________________________________________ to
________________________________. (His house) inclusive.
__________________________________________________________________________________
I hereby certify that the above statements are complete and true in every detail, and that
in consequence of the disease or disability above specified. The applicant was ill and inclusive
and that her/his claim is meritorious.

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This certificate is executed in the Philippines.
Affix here one P3.00 documentary stamp.
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(Signature)___________________________
Post-Office Address ___________________
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Date _______________________________