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Annex. D-I CERTIFICATE FOR HOSPITALIZATION To be completed in the case of patients who are admitted to hospital for treatment Certificate granted to Mrs. /Mr. /Miss husband /wife /son /daughter /mother /father of Mrs/Mr employed in the office PART A I Dr. hereby certify a that patient was admitted to hospital on b that the patient has been under treatment at and that 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. c treatment from to. d that the X-ray laboratory tests etc* for which an expenditure of Rs. was incurred were necessary and were undertaken on my advice at Signature and Designation of the Medical Officer In-charge of the case at the hospital. /Mr. /Miss husband /wife /son /daughter /mother /father of Mrs/Mr employed in the office PART A I Dr. hereby certify a that patient was admitted to hospital on b that the patient has been under treatment at and that 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. hereby certify a that patient was admitted to hospital on b that the patient has been under treatment at and that 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. c treatment from to. d that the X-ray laboratory tests etc* for which an expenditure of Rs. was incurred were necessary and were undertaken on my advice at Signature and Designation of the Medical Officer In-charge of the case at the hospital. /Mr. /Miss husband /wife /son /daughter /mother /father of Mrs/Mr employed in the office PART A I Dr. hereby certify a that patient was admitted to hospital on b that the patient has been under treatment at and that 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. c treatment from to. d that the X-ray laboratory tests etc* for which an expenditure of Rs. was incurred were necessary and were undertaken on my advice at Signature and Designation of the Medical Officer In-charge of the case at the hospital. .

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