ANNEX “A”

Republic of the Philippines

Department of Health
BAGUIO GENERAL HOSPITAL AND MEDICAL CENTER
Baguio City
Form no.: MS-HIM-004
Health information management office
Revision no.: 1
MEDICO-LEGAL CERTIFICATE
Effectivity date: July 1, 2015

___February 5, 2019 x
Date
TO WHOM IT MAY CONCERN:

This is to certify that MARIO H. TORRES (Male__ Female__) _25_ of age,

(Name of patient)

From #12B Zarate Village, Barangay Pinsao Proper, Baguio City f

(Address)

Was examined and treated/confined in this hospital on/from ______February 5, 2019________

(Date admitted)
to ______February 5, 2019_______ for the following:
(Date discharged)

laceration with hematoma at the left leg_ _____________________

__________________________________________________________________

TIME OF ARRIVAL: _______________________12:35______________ AM/PM

Brought by: __________RAMON TORRES_____ /Relationship: ____Uncle_____________
Address: #12B Zarate Village, Barangay Pinsao Proper, Baguio City x

Treatment will take from Six (6) to Ten (10) days for the above conditions/ injuries to
heal/recover unless complications will arise.

PROVISIONAL
FINAL
DY LIM, MD
Licence No. 214412
Department of ORL-HNS
Attending Physician / Medico-legal Officer