MRN

: 34400000001868
‫ر ﻗ ﻢ ا ﻟ ﻤ ﻠ ﻒ ا ﻟ ﻄﺒ ﻲ‬

Name : ‫ﻋﺒ ﺪ ا ﻟ ﺤ ﻜﻴ ﻢ ر ﺷﻴ ﺪ ﻋ ﻠ ﻲ ا ﻟ ﺴ ﻠﻴ ﻤ ﻲ‬
‫ااﻟﺲــم‬

Nationality : SAUDI ARABIA

‫ا ﻟ ﺠﻨ ﺴﻴ ﺔ‬

Hospital : Alkhoshiby PHC Age : 29 Y 10 M 0 D

‫ﻣ ﺴﺘ ﺸ ﻔ ﻰ‬ ‫ﻋﻤﺮ‬

Region : Qassim Date of Birth : 11-07-1993

‫ ا ﻟ ﻤ ﺤ ﺎ ﻓ ﻈ ﺔ‬/ ‫ا ﻟ ﻤﻨ ﻄ ﻘ ﺔ‬ ‫ﺗ ﺎ ر ﻳ ﺦ ا ﻟ ﻤﻴ ﺎ ﻟ ﺪ‬

Unit/Dept : Family Medicine Clinic Gender : Male

‫اﻟ ﻮ ﺣ ﺪ ة‬/ ‫اﻟ ﻘ ﺴ ﻢ‬ ‫ا ﻟ ﺠﻨ ﺲ‬

SICK LEAVE REPORT ‫ﺗﻘﺮﻳﺮ إﺟﺎزة ﻣﺮﺿﻴﺔ‬

Date of : 11-05-2023
Admission Date of Discharge : 11-05-2023
(‫)ﺗﺎ رﻳ ﺦ اﻟ ﺪ ﺧ ﻮ ل‬ (‫)ﺗﺎ رﻳ ﺦ اﻟ ﺨ ﺮ و ج‬

Place of work (‫ )ﺟﻬﺔ اﻟﻌﻤﻞ‬: Occupation (‫ )اﻟﻤﻬﻨﺔ‬: Public/Government sector (non-military)

Recommendation (‫ )اﻟﺘﻮﺻﻴﺎت‬:

Following medical examination, it is recommended

( ‫)ﺑﺎﻟ ﻜ ﺸ ﻒ ﻋﻠ ﻰ اﻟ ﻤ ﺮﻳ ﺾ ﻧ ﻮ ﺻ ﻲ ﺑﺎ ﻵﺗ ﻲ‬

Sick leave for days : 1 Starting From : 11-05-2023 To : 11-05-2023

( ‫) ﻣﻨ ﺢ إ ﺟ ﺎ ز ة ﻣ ﺮ ﺿﻴ ﺔ ﻟ ﻤ ﺪ ة‬ ( ‫) ا ﻋﺘﺒ ﺎ ر ا ﻣ ﻦ‬ (‫)إﻟ ﻰ‬

Follow up before end sick leave

Referral to medical committee for following reason

: Approval of sick leave / Can not be treated at this facility / Permanent or partial disability / Others

Treating Doctor Name : WALID SHAWGI HUSSEIN MOHAMED

( ‫) ا ﺳ ﻢ ا ﻟ ﻄﺒﻴ ﺐ ا ﻟ ﻤ ﻌ ﺎ ﻟ ﺞ‬

National ID/IQUAMA ID : 2335097768

(‫ا ﻹ ﻗ ﺎ ﻣ ﺔ‬/ ‫)ا ﻟ ﺮ ﻗ ﻢ ا ﻟ ﻘ ﻮ ﻣ ﻲ‬

Date of Birth : 01-01-1977

( ‫) ﺗ ﺎ ر ﻳ ﺦ ا ﻟ ﻤ ﻴ ﻼ د‬

License(SCFHS) : 12GM0057989
Number
( ‫)ا ﻟ ﺮ ﻗ ﻢ‬

Mobile Number : 0556084150

( ‫) ر ﻗ ﻢ ا ﻟ ﺠ ﻮا ل‬
Email ID : wsmohamed@moh.gov.sa
( ‫) ا ﻟﺒ ﺮ ﻳ ﺪ ا ﻻ ﻛﺘ ﺮ و ﻧ ﻲ‬

Physician Name : WALID

( ‫) ا ﺳ ﻢ ا ﻟ ﻄﺒﻴ ﺐ‬

/
‫إ ﺷ ﺎ ر ة إ ﻟ ﻰ إ ﺣ ﺎ ﻟﺘ ﻜ ﻢ ر ﻗ ﻢ ) ( و ﺗ ﺎ ر ﻳ ﺦ‬
‫ ﺑ ﺸ ﺄ ن ﻃ ﻠ ﺐ ا ﻟ ﻜ ﺸ ﻒ ا ﻟ ﻄﺒ ﻲ ﻋ ﻠ ﻰ ا ﻟ ﻤ ﻮ ﺿ ﺢ إ ﺳ ﻤ ﻪ‬/
‫ﺑﺸﺄن إﻟﻰ ﻣﺮاﺟﻌﺔ اﻟﻤﻮﻇﻒ ﻟﺪﻳﻜﻢ اﻟﻤﻮﺿﺢ اﺳﻤﻪ أﻋﻼه ﻟﻠﻜﺸﻒ‬
‫ﻋ ﻠﻴ ﻪ ﺗ ﺠ ﺪ و ن ا ﻟﺘ ﻘ ﺮ ﻳ ﺮ ا ﻟ ﺼ ﺎ د ر ﺑ ﺸ ﺄ ﻧ ﻪ‬

Companion Sick Leave

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Is Mandatory Required ? :

Is Saudi Patient? : Yes ‫ ﻧﻌﻢ‬/ No ‫ﻻ‬

(‫)ﻫﻞ اﻟﻤﺮﻳﺾ ﺳﻌﻮدي؟‬

National ID /IQAMA No. : IQAMA Expiry Date :

(‫) ر ﻗ ﻢ ا ﻻ ﻗﺎ ﻣ ﺔ‬ ( ‫) ﺗ ﺎ ر ﻳ ﺦ إ ﻧﺘ ﻬ ﺎ ء ا ﻹ ﻗ ﺎ ﻣ ﺔ‬

Date Of Birth : Mobile Number :

( ‫) ﺗ ﺎ ر ﻳ ﺦ ا ﻟ ﻤﻴ ﻼ د‬ (‫) ر ﻗ ﻢ اﻟ ﺠ ﻮا ل‬

Leave Beginning From :

( ‫) ا ﻷ ﺟ ﺎ ز ة ﺗﺒ ﺪ أ أ ﻋ ﺘ ﺒ ﺎ را ﻣ ﻦ‬ Sick Leave Duration :
( ‫) ﻣ ﺪ ة ا ﻷ ﺟ ﺎ ز ة ا ﻟ ﻤ ﺮ ﺿﻴ ﺔ‬

Companion Employer name :

(‫)ا ﺳ ﻢ ﺻﺎ ﺣ ﺐ اﻟﻌ ﻤ ﻞ اﻟ ﻤ ﺮا ﻓ ﻖ‬

Companion Job :
( ‫) و ﻇﻴ ﻔ ﺔ ا ﻟ ﻤ ﺮ ا ﻓ ﻖ‬

Relationship :
(‫) ﺻﻠ ﺔ اﻟ ﻘ ﺮاﺑ ﺔ‬

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