FORM B ESSENTIALITY CERTIFICATE

Certified that ......................................................................... wife

/son/daughter...........................................employed as...........................................
.............................................................................. has been under treatment
for ................... ........disese
from............................to .................................................

At the hospital.......................and that the under mentioned medicines were

Essentinal for recovery / prevention of serious deterioration in the condition of

the patient. The medicine are stock in................................hospital for the supply
to private patient and Do not includeproprietery preparations which are
primarily food and disinfectant.

Name of Medicines price

Signature and Designation of the

authorized medical Attedent