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Ravi gupt maurya
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45 views

Medical Form

Uploaded by

Ravi gupt maurya
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as PDF or read online on Scribd
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Central Institute of Higher Tibetan Studies (Deemed University) SARNATH, VARANASI ESSENTIAL BY CERTIFICATES CERTIFICATE 'A’ (To be completed in the case of patients who are not admitted to hospital for treatment) Certificate granted to Mrs./Mr./Miss .-.wife/son/daughter of Mr... employed inthe. (a) Thatl charged and received Rs... sseeeCONSULALIONS ON... ‘iven) at my consulting roonvat the residence ofthe patient. (©) That charged and received Rs. administering .. subcutaneous injections on . at. any consulting room /the residence ofthe patient. (©) That the injections administered were not/ were for immunising or prophylaetic purposes. (@ Thatthe patient has been under treatment at... hospital / my consulting room and that the undermentioned medicines prescribed by me in this connection were essential for the recovery / prevention of serious deterioration in the condition of patient. The medicines are not stocked in the. un. (name of hospital) for supply to private patients and do not include proprietary preparations for which cheaper substances of equal therapeutic value are available nor preparations which are primarily foods, toilets or disinfectants, (2) NAME OF MEDICINES PRICE (©) That the patient is / was suffering from. and is/was undermy treatment from... to.. (® Thatthepatientis/wasnot given pre-natal or post-natal treatment, (g) That the X-ray, Laboratory test etc. for which an expenditure of Rs. . incurred was necessary and were undertaken on my advice... the hospital orlaboratory). (h) That! referred the patient to Dr. specialist consultation and thatthe necessary approval ofthe... (name of the Chief Administrative officer of the State) as required under the rules was obtained. (i) Thatthe patient did not require / required hospitalisation. SIGNATURE AND DESIGNATION OF THE MEDICAL OFFICER AND HOSPITAL/ DISPENSARY TO WHICH ATTACHED.

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