MEDICAL CERTIFICATE FOR GENERAL PASSENGER

ENTRY INTO THE KINGDOM OF THAILAND

DATE

I, Roberta Maria N. Cawed-Mende, MD , am a certified medical doctor at

(name of M.D)

El Roi Medical Clinic and Diagnostic Center, Inc. , with license number 0108254 .
(name of hospital or clinic)

I examined on ,
(name of patient) (date of examination)

and have found free from the following disease:

(repeat name of patient)

Coronavirus Disease - 2019 (COVID-19),

following an RT-PCR test conducted at El Roi Medical Clinic and Diagnostic Center, Inc., on
(name of testing facility)

. Patient
(date of testing) (repeat name of patient)

exhibited no other signs of illness, and is deemed FIT TO TRAVEL to Thailand.

Signed:

Roberta Maria N. Cawed-Mende, MD

License number: 0108254

Hospital/clinic name: El Roi Medical Clinic and Diagnostic Center, Inc.

Hospital/clinic address: 994 San Andres St., Malate, Manila