Judetul ________________________

Localitatea ______________________
Unitatea sanitara _________________

Nr. fisa/carnet de sanatate

_______________________

ADEVERINTA MEDICALA
Se adevereste ca: __________________________________________ in varsta de ____ ani,
(numele si prenumele)

cu domiciliul in: judetul _____________________ localitatea _______________________

str._______________________________________________________ nr _____________
avand ocupatia de:____________________________ in ___________________________
Este suferind de: ___________________________________________________________
Se recomanda _____________________________________________________________
S-a eliberat prezenta spre a-i servi la : __________________________________________
Semnatura si parafa medicului.
Data eliberarii:
_________ luna ___________ ziua ______

LS _________________________