영문진단서

MEDICAL CERTIFICATION

문서서식포탈비즈폼

 

TEL.

DATE: ＿＿＿＿＿＿＿＿＿＿＿＿＿＿＿＿＿＿

(M)  (D)  (Y)

 

 

To Whom It May Concern:

 

 

Name: ＿＿＿＿＿＿＿＿＿＿＿＿＿＿＿＿＿＿＿＿＿＿＿＿

Date of birth: ＿＿＿＿＿＿＿＿＿＿＿＿＿＿＿＿＿＿＿＿＿＿＿＿              Sex: (□M, □F)

Home Address: ＿＿＿＿＿＿＿＿＿＿＿＿＿＿＿＿＿＿＿＿＿＿＿＿＿＿＿＿＿＿＿＿＿＿＿＿＿＿＿＿＿＿＿＿＿＿＿＿＿＿＿＿＿＿＿＿＿＿＿＿＿＿＿＿

 

 

This is to certify that the above named patient was examined on ＿＿＿＿/＿＿＿＿/＿＿＿＿  with the following results:

 

1. Diagnosis(□Impression, □Conclusion)                        I.C.D. ＿＿＿＿＿＿＿＿＿＿＿＿＿＿＿＿＿＿＿

 

 

 

 

2. Treatment:

 

 

 

 

3. Duration of Treatment(□Done, □Proposed):

 

 

 

 

Examined by: ＿＿＿＿＿＿＿＿＿＿＿＿＿＿＿＿＿＿＿＿   M.D

(signature)

 

 

○○ HOSPITAL

 

address: