C.S.C FORM 41 PHILIPPINE CIVIL SERVICE MEDICAL CERTIFICATE IherebywaiveallrightandprivilegespertainingtoproIessionalconIidencebetweenphysician andpatient,andthephysicianaccomplishingthisIormisauthorizedtoanswerindetailallquestions contained therein.

(Signature oI Applicant) ************************************************************************************* N.B.AttendingphysicianshouldIillintheblankbelow.Everydetailshouldbeansweredto avoid delay in action oI applicant Ior the above submitted by the patient. oI the bureau oI (Name oI Applicant) havingmade application Ior leaveoI absenceon accountoI illness, Idohereby certiIy that Iwill be theapplicant`s actual attending physician Irom 20 to 20 InclusiveandIrommyproIessionalknowledgeoIthecasetheIollowingstatementsaresubmittedas contemplated by the provision oI Section 8 oI Civil Service Rule XVI. NAME OF DISEASE: Nature oI disease or disability ************************************************************************************* Etiology:(UnderthisheadinginadditiontogivingIullytheetiologyoIthediseaseordisabilitythe physicianmust either state in the languageoI the Executive Order 'weather no identiIication whatsoever that the disease named was due to immoral or vices habit or give the indication. HISTORY: Description: A laboratory test or examination was Made in this case. The applicant was conIined to his/her house/hospital Irom to 20 inclusive. ************************************************************************************* IherebycertiIythatabovestatementarecompletedandtrueineverydetailandthatin consequence oI disease or disability above oI illness Irom 20 to 20 Inclusive and that his/her claim is meritorious. ( Signature ) M.D. P.O. Address DOC. STAMP