J.

P, Laurel Highway, Barangay Marawoy, Lipa City, Batangas

MEDICAL CERTIFICATE

This is to certify that Mr./Mrs. ___________________________________, ________ years old of

______________________________________________________, was confined/examined at this
hospital from_______________________________ to ________________________.

DIAGNOSIS

OPERATIONS DONE

Remarks

FOURTEEN

This certification is issued upon the request of the above-mentioned person exclusively for medical
purposes only.

Dr._____________________________
Licensed No._____________________
Dated issued ____________________
Prepared by:

Medical Records Officer

PS/MR-SD/FO-003 Rev#:00 Feb 1, 2020