CS FORM 41

MEDICAL CERTIFICATE

I hereby waive all rights and privileges pertaining to professional confidence between
physician and patient, and physician accomplishing this form is authorized to answer in detail
questions contained herein.

_________________________________
Signature of Applicant

(N.B.) Attending physician should fill the blanks below. Every detail should be answered to avoid
delay in action and application for leave submitted by the patient
________________________________ of the Department of Education, Division of Sarangani
Province, District of ________________________having made application for leave of absence
on ______________________to _______________________inclusive and from my professional
knowledge of the case of the following statements and submitted as contemplated by the
provisions of Section 8 of the Civil Service Rule XVI.

Name of the disease or disability __________________________________

Nature of the disease or disability _________________________________

(Under this heading, addition to giving all the etiology for the disease or disability, the
physician must either state in the language of the Executive Order. “There are no indication
whatsoever that the diseased named was due to immoral vicious habits” the indication.)

ETIOLOGY: ____________________________________________________________
____________________________________________________________
____________________________________________________________

HISTORY: ____________________________________________________________
____________________________________________________________
____________________________________________________________
____________________________________________________________

DESCRIPTION: ____________________________________________________________
____________________________________________________________
____________________________________________________________
____________________________________________________________
A Laboratory test or examination was done in this case. The applicant was confine to
his/her house/ hospital from _________________________, 20____ to
________________________, 20______.
I hereby certify that the above statements are complete and true in every detail, and
that in consequence of the disease or the disability of the above-specified applicants ill and
unable to inclusive and that his/her claim is meritorious.

Attached Documentary Stamp

_______________________
Signature of Physician
Lic. No.: _________________
Date: ___________________