Republic of the Philippines

Province of Pangasinan
MUNICIPALITY OF POZORRUBIO
Pozorrubio, Rural Health Unit Pozorrubio

Pangasinan
-oOo-

OFFICE OF THE MUNICIPAL HEALTH OFFICER

Date:_______________
MEDICAL CLEARANCE CERTIFICATE

TO WHOM IT MAY CONERN:

This is to CERTIFY that ______________________________________,________ years old ,

from Barangay ____________________________, Pozorrubio, Pangasinan has been
examined in this health facility and was found to be medically and physically fit at the time
of examination.

There are NO SIGNS AND SYMPTOMS of COVID-19 such as fever (______), cough,
sore throat, difficulty or shortness of breathing and, as such, is not considered as a suspect
for COVID 19 ARD.

Further certifies that the bearer of this certificate is not included in the List of Person Under
Monitoring/ Investigation (PUMs/PUIs) and thus, not undergone 14- day home Quarantine.

Issued on this day of _______________for whatever purposes it may best serve.

REMARKS:

Amount Paid Php: 130.00

Official Receipt. No. ____________ _________________________________
Date:___________ DR. MA. LUSIANA M. BAUTISTA
Municipal Health Officer
License Number 74568