FY Republic of the Philippines SOCIAL SECURITY SYSTEM MEDICAL CERTIFICATE (SSS FORM MMD - 102) 7 EMPLOYEE'S GENERAL DATA AGE] SEX] GIVI STATUS OCCUPATION NAME (Last, First, M1) 2 Domanrey , Ganan 32) F | Mate Froese Sarr DATE EXAVINEDIATTENDED From_Juvy’ 29 267+ qo ft. B 207 2. BRIEF CLINICAL FISTORY AND PRESENT PHYSICAL FINDINGS (Attach entra sheet needed) Cwvi0 1g sare ed POSIPVe 3K RAY LABORATORY ANDIOR SPECIAL DIAGNOSTIC EXAMINATION [Aach exia shee needed) lA 7 FINAL DIAGNOSIS z 5 CoviID 1a Lark cox Posie = C oerecteh VP RT -pce 5 EXACT DATE OF DISABILITY © KIND OF SURGICAL OPERATION PERFORMED, IF ANY (if claim Is for disability attach operating room record) ap 7-DATE OF OPERATION PERIOD OF MEDICAL ATTENDANCET CCONVALESCING OR RECUPERATION PERIOD TREATMENTIACTUAL SICKNESS , wt From JULY: 24,2rq, Aue. 9 OPV resales PLACE OR PLACES WHERE THE PATIENT WAS CONFINED DURING MY MEDICAL ATTENDANCE AND/OR TREATMENT PLAGEIS OF CONFINEMENT DATE FROM To Choe Ouevanti™ J TWA, 14,26) ] Hb. & , WP © OTHER REMARKS ‘PURSUANT TO SECTION 28 OF THE SOCIAL SECURITY LAW, AS AMENDED, ANYONE WHO RESORTS TO MISREPRESENTATION OR CONCEALMENT OF A MATERIAL FACT OR WHO IS A. PARTY THERETO, FOR THE: PURPOSE OF CAUSING ANY PAYMENT OF FRAUDULENT CLAIM OR BENEFIT UNDER THE SAID LAW, SHALL SUFFER THE PENALTIES OF FINE OR IMPRISONMENT OR BOTH. | HAVE THOROUGHLY EXAMINED THE HEREIN PATIENT/CLAIMANT AND THAT THE. ION ARE TRUE AND CORRECT. Mg ag 8/8 payer STRESECRONENG —SRECeSaRRENT OREGON NERA Muni of ‘STATEMENT OF WAIVER | HEREBY WAIVE ANY RIGHT OR PRIVILEGE | MAY HAVE ON ALL INFORMATION PERTAINING TO MY MEDICAL HISTORY AND | CONSENT TO ALLOW SSS TO EXAMINE ALL MY MEDICAL RECORDS. — b tpapuchausrPy RIGHT OR LEFT THUMBPRINT OF Cendlyn Demantoy PATIENT/CLAIMANT IF ILLITERATE anal De OR UNABLE TO WRITE PATIENTSICLAIMANT'S SIGNATURE, Internet Edition (7/2000)