PHILIPPINE CIVIL SERVICE

MEDICAL CERTIFICATE

C.S FORM 41

I hereby waive all rights and privileges to professional confidence between physician and
patient, and physician accomplishing this form is authorized to answer in detail all questions
contained herein.

NERINA T. CORPUZ

Signature of Patient

(N.B.: Attending physician should fill in the blank below, every detail should be answered to avoid
delay in action on applicant for leave submit by the patient).

Name of patient _________________________________ of the ____________________________

having made for 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 provisions of section 6 of Civil Service Rule XVI.

Name of disease or disability ________________________________________________________

Nature of disability ________________________________________________________________

Under this heading, in addition to giving fully the etiology of the disease or disability, the
ETIOLOGY physician must either state in language of the executive Order _______________.

There are no indicators whatever the disease name was due to immoral or vicious habits.

__________________________________________________________________________________

History _________________________________________________________________________

Description______________________________________________________________________
A LABORATORY TEST OR EXAMINATION WAS MADE IN THE CASE. The applicant was confined in the house hospital
from______________________ to _____________________________ inclusive.
 I HEREBY CERTIFY that the above statements are complete and true every detail and that in
consonance of the disease or the disability above specified the applicant was ill and unable to be on
duty on account of illness, from ___________________________________________________

__________ to _____________________, inclusive and that his/her claim is meritorious.

____________________________________

Signature of Physician

_____________________________

Post Office Address

_____________________________

License Number