REPUBLIC OF THE PHILIPPINES

PROVINCE OF CAVITE
MUNICIPALITY OF MARAGONDON

MEDICAL CERTIFICATE

_________________
Date

This is to certify that ________________________________________________, ______ (Age)

________________, resident of ___________________________________________________,

(Gender/Civil Status)

has been examined/ confined in this Health Unit on _______/______ due to check-up/ clearance.

This certification is used for _____________ purpose, except for legal purposes.

Diagnosis: ______________________________________

C.M. MALIGALIG-MORENO, MD
Municipal Health Officer
License no: _____________