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  • Philippine Civil Service Medical Certificate: Ivory C. Ymas

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    Lucenda Cabaylo
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    IVory C. Ymas has applied for a medical leave of absence from her job at the Department of Education. She signed a waiver authorizing her doctor to disclose details about her medical condition. Her doctor certified that she treated Ymas from [dates] for [disease or disability]. The doctor described the nature and etiology of the condition, any laboratory tests performed, and that Ymas was confined to her house from [dates] due to illness. The doctor certified that the information provided is true and complete, and that due to her medical condition, Ymas was unable to work from [dates].

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    IVory C. Ymas has applied for a medical leave of absence from her job at the Department of Education. She signed a waiver authorizing her doctor to disclose details about her medical condition. Her doctor certified that she treated Ymas from [dates] for [disease or disability]. The doctor described the nature and etiology of the condition, any laboratory tests performed, and that Ymas was confined to her house from [dates] due to illness. The doctor certified that the information provided is true and complete, and that due to her medical condition, Ymas was unable to work from [dates].

    Copyright:

    © All Rights Reserved
    Download as DOCX, PDF, TXT or read online from Scribd
    Flag for inappropriate content
    Download as docx, pdf, or txt
    94 views1 page

    Philippine Civil Service Medical Certificate: Ivory C. Ymas

    Uploaded by

    Lucenda Cabaylo
    IVory C. Ymas has applied for a medical leave of absence from her job at the Department of Education. She signed a waiver authorizing her doctor to disclose details about her medical condition. Her doctor certified that she treated Ymas from [dates] for [disease or disability]. The doctor described the nature and etiology of the condition, any laboratory tests performed, and that Ymas was confined to her house from [dates] due to illness. The doctor certified that the information provided is true and complete, and that due to her medical condition, Ymas was unable to work from [dates].

    Copyright:

    © All Rights Reserved
    Download as DOCX, PDF, TXT or read online from Scribd
    Flag for inappropriate content
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    of 1

    C. S.

    FORM 41

    PHILIPPINE CIVIL SERVICE


    MEDICAL CERTIFICATE

    I hereby waive all rights and privileges pertaining to professional confidence between physician
    and patient, and physician accomplishing the form is authorized in answer in detail question contained.

    IVORY C. YMAS
    (Name & Signature of Patient)

    _____________________________________________________________________________________
    N.B.- Attending physician should fill in the blanks below. Every detail should be answered to avoid delay
    in action on application for leave submitted by the patient.
    IVORY C. YMAS of the DEPARTMENT OF EDUCATION having made application for leave of
    absence on account of illness. I do hereby certify that I was the applicant’s actual attending physician
    from _______________ to ____________.
    Inclusive and from my professional knowledge of the case the following statement are
    submitted as contemplated by the provisions of Section 8 of Civil Service Rule XVI.
    Name of disease disability _________________________________________________________
    Nature of disease or disability__________________________________________________

    _____________________________________________________________________________________
    Under this heading, in addition to giving fully the Itiology of the Etiology: (disease or disability,
    the physician must either state in the language of the Executive Order). There are no inflication
    whatever, that the disease (name) was due to immoral or vicious habits or give the indications.

    _____________________________________________________________________________________
    _____________________________________________________________________________________
    ______________________________________________________________________________
    HISTORY
    _______________________________________________________________________________
    DESCRIPTION:

    A. LABORATORY test or examination was. . . . . . . made in case.


    (her house)
    The applicant was confined to ( ) from _______________ to
    ( )
    ______________, inclusives.

    _____________________________________________________________________________________
    I HEREBY CERTIFY that the above statements are complete and true in every detail, and that
    consequence of the disease or disability above specified the applicant was ill and unable to be on duty
    on account of illness from _________________ to ________________ inclusives, and that her claim is
    meritorious.

    ( NAME & SIGNATURE)

    ________________________________
    LIC. NO. ________________________

    Post Office Address:


    _______________________________

    DATE: __________________________

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