Divine Option

Clinic
Address: No 32 Odaliki Road Off Thomas Street
Tel: 08182636026, 08086770934
MEDICAL REPORT
SECTION A - To be completed by Applicant
Given Name and Initial Family Name
EMMANUEL ETUODICHUKWU ETUODICHUKWU

Home Address (No., Street, Apt. No., R.R.)

No, 13 Oluwa Olokodana Apapa Road

City, Town or Village Province or Territory Postal Code

Lagos mainland

Telephone number Date of Birth - (Year Month Day) Social Insurance Number
09018612177 14th, February 2002

SECTION B - To be completed by Physician

Please provide factual objective opinions
1. Height 2a. How long have you b. When did you start treating the patient c. Date of last visit
known the patient? for the main medical condition?
Year Month Day Year Month Day
Weight
2022 10 14

3. Diagnosis(es):

Catarrh And Cough

4. Relevant/significant medical history relating to the main medical condition:

None

SC ISP-2519 (2022-10-14) E