(To be completed in the case of patients who are not admitted to Hospital for treatment.)
Certificate granted to Mrs./Mr./Miss _________________________________________ Wife/Son/Daughter of
Mr. ____________________________________ employed in the office of the ___________________________
I, Dr. hereby certify,
That I charged and received Rs. ________________ for __________________ consultations on __________________________ (dates to be given) at my consulting room / at the residence or the patients;
That I charged and received Rs. ____________________ for administering _________________ intravenous / intra-muscular / subcutaneous injections on_____________________ (dates to be given) at ___________________ my consulting room / the residence of the patient.
That the injections administered were not / were for immunizing or prophylactic purpose.
That the patient has been under treatment at ________________________ hospital / my consulting room and that the under mentioned medicines prescribed by me in this connection were essential for the recovery / prevention of serious deterioration in the condition of the patient. The medicines are not stocked in the ______________________ (names of hospitals) for supply to private patient and do not include proprietary preparations for which cheaper substances of equal therapeutic value are available nor preparations which are primarily foods, toilets or disinfectants.
|Sr. No.||Name of Medicine||Price|
That the patient is / was suffering from _____________ and is / was under my treatment from _____________________ to _____________________
That the patient is / was not given pre-natal or post – natal treatment.
That the X-ray, Laboratory test, etc. for which an expenditure of Rs. ___________________ was incurred was necessary and were undertaken on my advice at __________________________ (name of the Hospital or Laboratory).
That the patient did not require / required hospitalization.
That the ailment is/is not a chronic ailment and medicines at S.No. _________________________ above are required for prolonged treatment of the chronic ailment and will need ot be taken for at least ______________________ days / 3 months / __________________
Signature & Designation
of the Medical Officer
and Hospital / Dispensary
to which attached