CS. FORM 41 PHILIPPINE CIVIL SERVICE Medical Certificate Thereby waive all rights und privileges pertaining to profeesional confidence betyeea physician snd patient accomplishing this form is enthorized to anewer in detail all question containing herein. (Signature of patient) eeeeeeeSeSeeSeeSeSseSe N-B: Attending physicien should fill in the blenk below, avery detail question shov'd be anawered 0 avoid delay in ection on application for loave subvnitted by the Paticot: of the Department of Education. Having made (Name of patient) ~ ‘ap; “ication for teave af absence ou, > ‘attending physician from inclusive und from my profegaianal knowiedge of the case the following stuieneai are wibmitied, as contemplated by Provision of section 7 of Civil Service Rule XV. Name of Disease or Disability Nature of Divense or disability Under this beading, in addition to giving fully the Ratio log of RETOLOGY. The diccase or disability the physician must either state in language of Executive Order, here thers are no indications whatever the disease named was duc Lo immoral or vicious habits Laboratory test or examination was a cuss. The applicant was confined to his home from Incivoive. THEREBY CERTIFY that the statement are completed aad true to every detail ‘ax! “ot in consequence of the diseases or the disability above specified the applicant wes alt cd unable to be sccount of illness from is ial tof Sniatested Inciusive, and that his ‘her claim is notorious.