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Republic of the Philippines

Department of Education
Region V – Bicol
Schools division of Legazpi City

MEDICAL CERTIFICATE
_______________________
(Date)

TO WHOM IT MAY CONCERN:


This is to certify that I have personally examined the person indicated below
with the findings and recommendation as stated:

Name: ___________________________________ Age: ________ Sex: ________


Birthday: ______________
Height: _________ Weight: _____________ Blood Pressure: ______________
Pulse, Resting:__________________________ Respiratory Rate: ______________

Other Remarks: _______________________

Physical Examination
___________________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________
___________________________________________________________________

This certifies further that he/she did not exhibit symptoms related to COVID-19
at the time of physical examination.

Date examined: ______________________

`
______________________________
Physician/Medical Officer
License No. ______________
PTR: ______________

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