MEDICAL CERTIFICATE

TO WHOM IT MAY CONCERN:

This is to certify that _______________________________, ____________years old
(Male, Female), (Single, Married) Child, residing at
_____________________________________________________________________________________
(Confined, Consulted, Treated) in this hospital on __________________________________
from _____________________________________ to ______________________________because
of
_____________________________________________________________________________________
____________________________________________________________________________________.
DIAGNOSIS:________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
Remarks/Recommendation:_________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________

This certification is issued upon this request of the interested party for
whatever purpose may serve.
Note: NOT FOR MEDICO LEGAL PURPOSES

_______________________ MD
Attending Physician
Lic.
No.:____________________

NOT VALID WITHOUT SEAL