CERTIFICATE ‘A’ : From No. 6(11)(a) (To be completed in the case of a patient who is not admitted in the Hospital) Certificate granted to Father/Mother/Husband/Wife/Daughter/Son of ShrvSmt... = {employed inthe office ofthe food Corporation of India at New Delhi (@) 1, Or. hereby certiy that 1 have charged and received in Cash Ris. for consultation on at residence of the patient/at my consulting room. (b) That | nave charged and received in cash Re. ssmeonnedor administering, intravenous/intra-muscular injections on at my consulting roomie residence ofthe patient (c) That the injection administered were not for immunising or prophylactic purposes. (d) That the patient has been under my treatment at my consulting room outside the hospital hours and that the serious deterioration in the condition of the patient. The medicines are not stoked in the dispensary/Government hospital for supply to private patient and do not inolude proprietary preparations for which cheaper substances of private patient and do not include proprietary preparations for which cheaper substance of equal therapeutic value are available or preparation which are primarily foods, tollets of disinfectants. ‘Name of the Medicines Price ‘Name of the Medicines: Price (e) That the patient is/was suffering from..... from... aoe (f) That the patient is/was not given pre-natal or post-natal treatment (g) That the X-ray, laboratory tests, etc. for which an expenditure of Rs. and isiwas under my treatent (Rupees. ) was incurred were necessary and were undertaken on my advice at Government Hospitaliprivate Clinic. (h) That I referred the patient 10 Dri.nunnmnmnnnsunnfOF Specialist consulation. (i) That the patient did not require hospitalisation. () Certified that the disease was not the prolonged treatment. (K) Certified that Dr. Aan was consulted by the patient on my advice and the consultation was essential for the speedy recovery ofthe pation. The Dr. consulted has charged Rs. towards consultation fees. () That the patient has reasonable chance of recovery if he is treated as an out-patient. (m) That the treatment in excess of the prescribed period of ten days was essential for the recovery of the patient, (n) That the mixture/powder could not dispensed in the hospital and authorised the purchases from the chemist (0) Certified that | am practising medicine for more than 10 year. (p) Certified that | am practising Alopathic system of medicine and am permitted to do so. (q) That the patient did not require required leave during the period of treatment. Signature of the Medical Officer Registration No. Dated. os Degree