Date,_____________________

MEDICAL CERTIFICATE

TO WHOM IT MAY CONCERN,

This is to certify that M________________________________________, of

______________________________, was examined and treated in this hospital by the
undersigned Diagnosis of __________________________________________.

It is further certified that he/she is fit to resume to his/her duties at work.

This Medical Certificate is issued upon the request of

___________________________________ for whatever purpose it may serve him/her.
__________________________ M.D.
Attending Physician