..................Hospital
..........................Rd
.............................
Tel.......................
Day......Month.....B.E...............
I am...................................................................................................M.D.
holding license to practice medicineNo................issued on Day..........Month...........B.E/AD………………
have examined..........(name).......onDay..... Month......B.E/AD........
and have found that ........(name)........……………………
........................(name)........is ingood physical and mental health and free from any defect and contagious
diseases.
Signature..................................M.D.
..........................Rd
.............................
Tel.......................
Day......Month.....B.E...............
I am...................................................................................................M.D.
holding license to practice medicineNo................issued on Day..........Month...........B.E/AD………………
have examined..........(name).......onDay..... Month......B.E/AD........
and have found that ........(name)........……………………
........................(name)........is ingood physical and mental health and free from any defect and contagious
diseases.
Signature..................................M.D.