CSC FORM 41 MEDICAL CERTIFICATE

PHILIPPINE CIVIL SERVICE

MEDICAL CERTIFICATE

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

______________________________
(SIGNATURE OF PATIENT)

(NAME OF PATIENT)______________________________________________of the Bureau

of public schools having made application for leave of absence account of illness, I do
hereby say that I was the applicant’s actual attending physician for ____________________
___________________________to______________________________ inclusive and from
my professional knowledge of the following statement are submitted as completed by the
provision of Section 8 of Civil Service Rules No. IV.

Name of Disease or Disability_________________________________________

Nature of Diseases or Disability________________________________________

Etiology, under this heading in addition to giving full the etiology of the disease or
disability, the physician must either state in the language of Executive Order, there are
non-medications whatever that the disease named was due to immoral or vicious habits or
give the indications.

HISTORY ________________________________________________________

DESCRIPTION____________________________________________________

A laboratory test or examination was deem done in this cause, the application
contains confined to (Her/His) house, hospital from__________________________________
__________________________________ inclusive.

I HEREBY CERTIFY that the above statements are complete and true in every
detail and that consequence of the disease or disability above specified the applicant was ill
and unable to be on duty on account of illness from ________________________________to
____________________________________.

__________________________________________
(Signature of Physician)

________________________________
(Date)

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