CS Form No.

41

EXAMINATION CIVIL SERVICE

MEDICAL CERTIFICATE

I hereby waive all rights and privileges pertaining to professional confidence between
physician and patient and the physician accomplishing this form is authorized to answer in detail
all questions contained therein.

______________________
(Signature of Patient)
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N.B. Attending physician should fill in the blanks below. Every detail would answered to avoid
delay in notice of applications for leave submitted by the patient. ___________________ of the
Bureau of Elementary Education, (Name of Patient)

Of _______________________________ having made application for leave on account’s actual

and attending physician from __________________,_______ to ___________________,______,
inclusive and from my professional knowledge provision of Section 7 of Civil Service Role XVI.

Name of disease or disability____________

Name of disease or disability____________

( Under this heading, in addition to giving fully the etiology of the disease of
(disability, the must either state in the language of the Executive Order. “There are no
(indications whatever that the disease named was due to immoral or vicious habits” or
(give the indications.

______________________________________________________________________________
______________________________________________________________________________

History:_______________________________________________________________________
________________________________________________________________________

Description:____________________________________________________________________
______________________________________________________________________________
________________________________________________________________________
A laboratory test or examination was ________ made in this case.
The applicant was confined to his house/hospital from ________________, to
__________________, inclusive.
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I HEREBY CERTIFY that the above statements are completed and true in every detail,
and that in consequence of the disease or the disability above specified the applicant was ill and
unable to be on duty on account illness from ___________________ to ___________________.

(Signature)_______________
(Post Officer Address)

________________________