(To be completed in the case of patient who are not admitted to hospital for treatment) med.

103 from

Certificate granted to Mrs. / Mr./ Mrs. Mr. ..

Employed in

CIVIL COURT BIJNOR

CERTIFICATE A

(To be signed by the Medical officer-in-charge of the case at the hospital)

1. Dr. HEREBY CERTIFY:

(a) That I charged/ received Rs for consultation or consultation or
at my consulting room/at the residence for the patient.
(b) I charged/received Rs.. for administrating.. in tramuscular
substances injunction on at my consulting room/at the residence for the
patient.
(c) That the patient has been under treatment at . .
Hospital/ my consulting room and the under mentioned medicines prescribed by me in this
connection were essential for the recovery/prevention of serious deterioration in the
condition of the patient. The medicines are not stocked in the (Name of the Hospital.)
for supply to private patients and do not include proprietary preparations
for which cheaper substances off equal therapeutic value are available nor preparation are
primarily food, toilets or disinfectants.
SL. NO. NAME OF MED/BILL AMOUNT SL. NO. NAME OF MED/BILL AMOUNT
NO.& DT. NO.& DT.

Total Amount Rs.

(d) That the patient is/was suffering from .. and is /was under my treatment
from dt. . To .. .
(e) That the patient is/was not given prenatal or post treatment.
(f) That the X-Ray, laboratory test etc. For which an expenditure of Rs. .. incurred were
necessary and were undertaken on advice at . .
(g) That I referred the patient to Dr. for specialist consultation and that the
necessary of the .. as acquired (Name of the Chief Administrative
medical office of the state) under the rules was obtained.
(h) That the patient do not require/required under the rules for hospitalization.
(i) That I am not drawing any NPA. NPP.
Date
 Signature & Designation of
Medical office of the
Hospital/dispensary to which
attached.
N.B. Certificate not applicable should be struck off Certified (A) is compulsory and must be
filled in by Medical officer in all cases.

COUNTERSIGNED
I certify that the patient has been under treatment at the .. Hospital and
that the facilities provided were minimum, which were essential for the patients treatment.
Date:../2016
Place:
Medical Superintendent of the
___________________Hospital