CIVIL SERVICE FORM 41

PHILIPPINE CIVIL SERVICE COMMISSION

MEDICAL CERTIFICATE
I hereby waive all rights and privileges pertaining to profession all confidence between
physician and patient, and the physician accomplishing this form is authorized to answer in
details all questions contained herein.
REBECCA M. LAPIDARIO
(Signature of Patient)

(N.S.) Attending physician should fill on the blanks below. Every detail should be answered to
avoid delay in action on application for leave submitted by the patient.

REBECCA M. LAPIDARIO of the BARAS ELEMENTARY SCHOOL

(Name of Patient) BARAS, PALO, LEYTE
(Name of Office)
Having made application for leave of absence and account of illness. I do hereby certify
that I was the applicant’s actual attending physician from JUNE 03- SEPTEMBER 16, 2021
inclusive from my professional knowledge of the case. The following statements are submitted,
as contemplated by the provision of section 8 of the Civil Service Rule XVI.

Name of diseases or disability:

______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
Nature of disease or disability: ___________________________________________________
Under this heading, in addition to giving fully the etiology of the patient.
ETIOLOGY:(disease or disability), the physician must state in the language of the Executive
Order. There are no indications whatever that the disease ( named was due to immoral of vicious
habits or give the indications.)
“
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
HISTORY:
Laboratory test or examination was___________________________made in this case. The
applicant was confined in his/her (house/hospital) from JUNE 03- SEPTEMBER 16, 2021.

I hereby certify that the above statement are complete and true in every detail, and that the
consequence of the disease or disability above specified, the applicant was ill and unable to be on
duty on account of disease from JUNE 03- SEPTEMBER 16, 2021 inclusive and that her.his
claim is meritorious.
________________________________
At this certificate is executed in the
Philippines: Affix
_______________________________

_______________________________
Doc. Stamp Signature of Attending Physician
Date:______________ Postal Address
EASTERN VISAYAS REGIONAL
MEDICAL CENTER