Judetul ________________________ Nr.

fisa/carnet de sanatate
Localitatea ______________________
Unitatea sanitara _________________ _______________________

ADEVERINTA MEDICALA

Se adevereste ca: __________________________________________ in varsta de ____ ani,

(numele si prenumele)
cu domiciliul in: judetul _____________________ localitatea _______________________
str._______________________________________________________ nr _____________
avand ocupatia de:____________________________ in ___________________________
Este suferind de: ___________________________________________________________
Se recomanda _____________________________________________________________
S-a eliberat prezenta spre a-i servi la : __________________________________________

Semnatura si parafa medicului.

Data eliberarii:

_________ luna ___________ ziua ______ LS _________________________