CERTIFICATE OF CONFINEMENT

______________
(Date)

TO WHOM IT MAY CONCERN:

THIS IS TO CERTIFY that _____________________________________, _______ years old,

(Name of Patient) (Age)

_____________, _____________ from ___________________________________ was examined and

(Gender) (Civil Status) (Address)

confined in this hospital on / from ___________________________ to __________________________

under the service of ________________________________.

(Name of Physician)

This certification is being issued upon request of ____________________________ for

(Name of Requester)
whatever purpose it may serve them.

______________________________
Attending Physician

PRC Licence No.: ___________________

PTR No.: ___________________