Physician profile
Physician 1
Physician 2
[PHYSICIAN NAME, CREDENTIALS]
[SPECIALTY]
[CLINIC / PRACTICE NAME]
[ADDRESS]
[PHONE] · [EMAIL]
[PHYSICIAN NAME, CREDENTIALS]
[SPECIALTY]
[CLINIC / HOSPITAL AFFILIATION]
[ADDRESS]
Date:
Patient:
Address:
Age / Sex:
RX
+ Add medicine
− Remove last medicine
Notes:
Follow-up:
Physician's signature — sign below
Clear signature
[PHYSICIAN NAME, CREDENTIALS]
PRC License No. [PRC NUMBER]
PTR:
[PHYSICIAN NAME, CREDENTIALS]
[SPECIALTY]
[CLINIC / HOSPITAL AFFILIATION]
[ADDRESS]
MEDICAL CERTIFICATE
Date:
TO WHOM IT MAY CONCERN:
This is to certify that
,
years old,
, residing at
, has been seen and examined in this clinic on
with the following diagnosis:
RECOMMENDATION / RX
Advised to rest for
day(s)
Fit to return to work
Fit to work
Fit to travel
Cleared for school admission / school activities
For further work-up and referral
Details / referral:
Additional remarks:
This certificate is issued upon the request of the patient for whatever purpose it may serve except medico - legal purposes.
Physician's signature — sign below
Clear signature
[PHYSICIAN NAME, CREDENTIALS]
PRC License No. [PRC NUMBER]
PTR:
Prescription (RX)
Medical Certificate
Preview
Print
Save PDF
Share PDF
Clear current form
