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Certificate-A
(To be completed in the case of patient who are not admitted to hospital for
treatment)
Certificate granted to Mrs./Mr./Miss………................................……………………………….
Wife/son/daughter of Mr……………………………………………………………….……………………………..
Employed in the……………………..........................…………………………….……………………………
Dr………………………………………………………………………………………….hereby certify.
(a) That I charged/received Rs…………………….for consultations on ………………………at
my consulting room/at resident of the patient.
(b) That I charged and received Rs………………………for
administerin………………………….. inter-muscular/sub cutaneous injections on
date………………..at my consulting room/at resident of the patient and the injections
were for immunizing or prophy lactic purposes.
(c) That the patient has been under the 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 serius deterioration in the condition of the patient. The
medicines are not stocked in (name of the
hospital)……………………………………………………………………
…………………………………………………………..for the supply to privet patients and do not
include proprietary preparations for which cheaper substance of equal therapeutic
value are available not preparations which are primarily foods, toilets and
disinfectants.
--------------------------------------------------------------------------------------------
Sl. Name of medicines Quantity Price
1.
2.
3.
4.
5.
6.
(d) That the patient is/was suffering from………………….........................……………………
And it was under my treatment from…………....................……to……….............………….
(e) That the patient is/was not given prenatal or post-natal treatment.
(f) That the X-ray laboratory test, etc for which an expenditure of
Rs…………………………as incurred
Were necessary and were under taken on my advice at…………………..........……………….
(g)That I referred to Dr………………………………………………………………………………for
specialist consultation and that the necessary of
the………………………………………………………………..as requires under rules was obtained.
(h) That the patient did not require/required under the rules for hospitalization.
(I) I am not drawing any NPA/NPP.
Date…………………………………….
Signature and Designation
Of the medical officer in-charge
Of the case at hospital
COUNTER SIGNED
I Certify that the patient has been under the treatment as
the……………………………………………………..
…………………………………………………………………………………………………………………………….Hospit
al and that the facilities provide were the minimum which essential for the patient
treatment.
Place……………………………………………
Date……………………………………………
Medical Superintendent of
Hospital
Certificate-B
(To be completed in the case of patient who are not admitted to hospital for
treatment)
Certificate granted to Mrs./Mr./Miss………………...............……………………………………….
Wife/son/daughter of Mr………………………………….............………….……………………………..
Employed in the……………………………..................………………………….……………………………
PART-A
(To be singed by medical officer in-charge of the case at the hospital)
1. Dr…………………………………………………………………….hereby certify.
(a) That the patient was admitted to hospital on my advice/the advice
of……………………………….........................................................................
................................................……………………………………………………………….
(Name of the medical officer)
(b)That the patient has been under treatment at……...........................………………….
………………………………...................................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 patients.
2. The medicines are not stocked in the…………………......................……………………..for
supply to privet patient and do not include proprietary preparations for which
cheaper substance of equel therapeutic value are available not preparations which
are primarily foods & disinfectants.
--------------------------------------------------------------------------------------------
Sl. Name of medicines Quantity Price
1.
2.
3.
4.
5.
(c ) That the injections administered were/were not for immunizing or prophylactic
purposes.
(d ) That the patient is/was under my treatment from…………................……………….…
and is/was under my treatment from……....……………….......to………………..........………….
(e )That the X-ray laboratory etc. for which an expenditure of Rs……………………..was
incurred were necessary and were undertaken on my advice at………………..……………..
(Name of the Hospital/Laboratory)
That referred the patient to Dr………………………………for specialist consultation and
that the necessary approval of the …………………………………………………………………....……….
………………………..(Name of the chief administrative Medical Officer state)
Signature and Designation of the
Medical Officer in-charge of the
Case at the Hospital
PART-B
I certify that the patient has been under treatment at the …………………………………………
……………………………………………………………………………………..hospital and that the services
of the special nurses for which expenditure Rs…………………………………..was incurred
vide bills and receipts attached, were essential for the recovery/prevention of serios
deterioration in the condition of the patient.
Signature and Designation of the
Medical Officer in-charge of the
Case at the Hospital
COUNTERSIGNED
I certify that the patient has been under treatment at the …….........…………………………
………………………………………………….hospital and the facilities provide were the minimum
which essential for the patient treatment.
Place…………………………….. Medical Superintendent
Date…………………………….. Hospital
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