1. Medical Council of IndiaNotification - 2002
� FORMOFCERTIFICATERECOMMENDEDFORLEAVEOREXTENSIONORCOMMUNICATIONOFLEAVEANDF
Signature of patient
or thumbimpression��������� ___________ __ __ __ _ _ __ _ _ __ _ _ __ _ _ __ _ _ __ _ _ __
To be filled in by the applicantin the presence of the GovernmentMedical Attendant, or MedicalPractitioner.
Identification marks:�� -
I, Dr.____________ __ __ __ __ _ _ __ _ _ __ _ _ __ _ aftercareful examination of the case certify hereby that ___________ __
absolutely necessary forthe restoration of his
health.���������������������������������������
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Dr.____________ __ __ __ __ _ _ __ _ _ __ aftercareful examination of the case certifyhereby that_____________ __ __ __ _
Place___________ __ __ __ _ Signature of Medical attendant
Date_____________ __ __ __ Registration No.____________ __ __ __ _