Republic of the Philippines

____________

MEDICAL CERTIFICATE

TO:

___________________________
Presiding Judge
RTC/MTC Branch ____
National Capital Judicial Region
____________________

Your Honor:
THIS IS TO CERTIFY, that (Name) _____________________________________________,
_____years old, male, single/married has been examined on ______________________________ and
diagnosed to be suffering from ________________________________________________________.

TREATMENT/RECOMMENDATION:

Medical Officer/Surgeon
License No. ___________