HEALING PROGRESS FORM

Patients Name :
NRIC Number :
Policy Number :

Date of Condition of Injuries Degree of Physical/Mental

Consultion Disability in relation to the
Healing progress

I hereby certify that I have personally examined and treated the patient for his /her injuries described above and
that the facts as stated above are all true to the best of my knowledge.

........... ........... ...........

Signature of Attending doctor Name & Practice stamp Name & Address of
Hospital / Clinic
Date :
Telephone no :.