PHILIPPPINE CIVIL SERVICE

MEDICAL CERTIFICATE

I hereby waive all right and privileges pertaining to professional confidence

between physician and patient, and the physician accomplishing this form are authorized
to answer in detail all questions continued herein.
MRS. KAREN I. ZARAGOZA
(Signature of the
Patient)

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

Mrs. Karen I. Zaragoza of the Department of Education Deped-Balanga City

(Name of Patient.)
Having made application for leave of absence on account for illness, I do hereby certify
that I was the applicants attending physician from __________ to _________________
Inclusive, and from my professional knowledge of the case following the statement as
submitted, as contemplated by the provisions of Section 8 of Civil Service Rule XVII.

Name of Disease or disability _____________________________

Nature of disease or disability _____________________________

(Under this heading, in addition to fully giving the etiology of the disease
(Or disability, the physician must state in the language of the Executive
(Or Order. “There are no indications whatever that the disease named was due
(To immoral or violent habits” or give the indications.

History

Description

A laboratory test or examination was

The applicant was confined to (his house) From __________, 2020 ___________
To________________, 2020________inclusive.

I HERE CERTIFY that the above statement are complete and true in every detail,
Documentary stamp

and that in consequence of the disease or disability above specified that applicant was ill
Affix PhP.15.00

and unable to be on duty on account of illness from_________,2020_________, to _____

2020,_________, inclusive, and that his claim is meritorious.

(Signature)_______________________M.D.
(Post Office Address____________________

Date _________________, 2020__________