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Judetul____________________ Judetul____________________

Localitatea_________________ Localitatea_________________
Unitatea sanitara__________________________ L.S. Unitatea sanitara__________________________ L.S.

Certificat medical Nr._____________ Certificat medical Nr._____________


2017 luna_____________ziua_____ 2017 luna_____________ziua_____

Se certifica de noi ca:d-(na)nul Se certifica de noi ca:d-(na)nul


_________________________________in virsta de_______ani ____________________________________in virsta de_______ani
sexulM/F,domiciliat in judetul__________________________ sexulM/F,domiciliat in judetul__________________________
localitatea_______________str.________________nr.______ localitatea_______________str.________________nr.______
cu buletinul de identitate seria_______nr._________________ cu buletinul de identitate seria_______nr._________________
avind ocupatia ______________________________________ avind ocupatia ______________________________________
la intreprinderea/institutia_____________________________ la intreprinderea/institutia_____________________________

Este suferind de : Este suferind de :


NEUROLOGIE ___________________________________ NEUROLOGIE ___________________________________
__________________________________________________ __________________________________________________
__________________________________________________ __________________________________________________
__________________________________________________ __________________________________________________
PSIHIATRIE ______________________________________ PSIHIATRIE ______________________________________
__________________________________________________ __________________________________________________
__________________________________________________ __________________________________________________
___________________________________________________ ___________________________________________________
MEDICINA INTERNA: _____________________________ MEDICINA INTERNA: _____________________________
___________________________________________________ ___________________________________________________
___________________________________________________ ___________________________________________________
___________________________________________________ ___________________________________________________

S-a eliberat prezentul pentru a-i servi la S-a eliberat prezentul pentru a-i servi la
_________________________________________________ _________________________________________________
L.S. L.S.

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