Sample Medical Examination Certificate Template

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F
Medical Certificate
................................................................
Date
F
F
F . ........................................................................................
F
Name
a medical doctor
....................... ก F
..............
............... . ...............
Holding medical license No.
issued on date
month
A.D.
F ก
F ก ..............................................................................
.............................................
have examined
(name)
on date
F
ก F ..............................................................................................................
F
and have found
(name)
free of the following diseases
1.
LEPROSY
2.
TUBERCULOSIS (T.B.)
3.
F F
ELEPHANTIASIS
4.
F
DRUG ADDICTION
5.
3
THIRD STEP OF SYPHILIS
..
F F ก
F F
F
(name)
is in good physical and mental health
F
F
F
F ก
ก F F F
free from any defect
..........................................................
F F
Signature
M.D.
(
)
Name (in print)
Address
.
.
Tel (
) .

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