CERTIFICATE 'A'

(To be completed in the case of patients who are not admitted to Hospital for treatment)

Certificate granted to Smt/Sri/KumR S Redhu, SO-D.................................................... Wife / Husband / Son / Daughter / Father / Mother of Sri .........Rattiram employed in the office of Atomic Minerals Directorate for Exploration & Research, Bangalore. I, Dr.______________________________________ hereby certify a) that I charged and received Rs.________for__________ consultations on_________ at my consulting room/ at
b) c) d) the residence of the patient, outside hospital hours. that I charged and received Rs. ___for administering _ injections Intra-venous /Intra-muscular /subcutaneous injections on__ at my consulting room/at the residence of the patient outside the hospital hours. that the injections administered were not for immunising or prophylatic purposes. that the patient has been under treatment at M C Palle Camp that the undermentioned 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______ hospital for supply to private patients and do not include proprietary preparations for which cheaper substances of equal therepeutic value are available, nor preparations which are primarily foods, toilets or disinfectants. SNo Medicines Quantity IN CAPITAL LETTERS) Rs. ...... Ps.

1. 2. 3. 4. 5. 6. 7. 8. 9. 10. TOTAL : e) f) that the patient is/was suffering from __________________________________ and is/was under my treatment from _____________________ to____________________ that the patient is/was treated for : i) Immunizing and prophylactic purposes ii) sterility or sterilization iii) venereal diseases and delirium treatments that it is /was not a case of i) pre-natal or post-natal routine check up ii) eyesight testing for glasses

g)

h)

that the X-ray, laboratory test etc., dated __________________ for which an expenditure of Rs.____________was incurred was necessary and were undertaken on my advice at ___________________________ which is a Government Laboratory / Hospital. that the patient did not require/ required hospitalisation;

i)

j) k)

that I am of equivalent rank/immediately junior rank attached to the same hospital as he is viz __________ _______ _______________________________________ hospital. that the ______________________ ointment/mixture entered at item ________ under certificate No. (d) on reverse, could not disposed in the Government Hospital Laboratory and the patient was advised to purchase it from the market. that I referred the patient to the _________________________________ which is the nearest Government/State-aid maintained by local authority/private hospital from the place where the patient fell ill and which in my opinion could provide the necessary and suitable treatment. that I referred the patient to Dr. ________________________________________ specialist/ MO in Government employment in that _________________________ for specialist consultation and the necessary approval of the _________________________________________________ as required under the rules was obtained, vide his letter/Memo No.__________________________ that the case is not for prolonged treatment. that I am not on long leave during the period of treatment. that I am not entitled to draw non-private practicing allowance. __________________________________ Signature, Designation, Degree and Regd. No of the Medical Officer and the Hospital/ Dispensary to which attached

l)

m)

n) o) p)

Place:________________

/Date:________________ Note: Certificates not applicable should be struck off. Certificates are compulsory and must be filled in by the Medical Officer in all cases.