E.

PERLAS DIAGNOSTICS & POLYCLINIC

93 Pio Valenzuela St., Marulas, Valenzuela City 1440 Philippines
Tel No. 432-5942/293-5884

MEDICAL CERTIFICATE
Patient’s Name: (Last, First, Middle) Age: Sex:

This is to certify that the above patient was seen and examined on _________________

Patient’s Complaint/s: _____________________________________________________

________________________________________________________________________
________________________________________________________________________

Clinical Impression: ________________________________________________________

Remarks: ________________________________________________________________

Note: This medical certificate is not intended for medico-legal purposes.

______________________________ _____________
Consultant Date
License No.:____________ PTR: _________________