Medical Certificate Template

Medical Certificate
Date: _____________________
I the Undersigned Doctor in Medicine, _____________________________________________

Certify that I have examined the blood test results

Mr. /Mrs. ______________________________________________________________________

Nationality: _______________________________________________________

Date of Birth: _____________________________________________________

Place of Birth: _____________________________________________________

Age: __________________________ Marital Status: _____________________

Residing At: ______________________________________________________

I have found her:

Free of Following Illnesses:

 HIV/AIDs
 Heptatitis b and c

Issued At: _________________________________________ on: ____________________________________

Doctor Sign: _____________________________ Stamp: __________________________