BERNARDINO GENERAL HOSPITAL

[ ] Quirino Highway,San Bartolome, Novaliches Q.C.

[ ] NorthOlympus, Zabarte Road, Novaliches Q.C.

MEDICAL CERTIFICATE

Date:_______________________

This is to certify that:_____________________________________________________________________________________

Age:________________Sex:________________Status:___________________________Occupation:____________________

Address:_______________________________________________________________________________________________

___________________________________________________________________________________________ is under care

Medical Care & Treatment:_______________________________________________________________ with the following

Findings:______________________________________________________________________________________________

Diagnosis:______________________________________________________________________________________________

Recommendation:_______________________________________________________________________________________

Remarks:_______________________________________________________________________________________________

________________________
AttendingPhysician

Lic No._______________
T I N ________________
FORM 06-96