FORM OF CERTIFICATE RECOMMENDED FOR LEAVE OR EXTENSION OR COMMUNICATION OF LEAVE AND FOR FITNESS

}Signature of patient
or thumb impression ___________________________________________

To be filled in by the applicant in the presence of the Government Medical Attendant, or Medical Practitioner.

Identification marks:-

◦__________________________

◦__________________________

}I, Dr. _____________________________________ after careful examination of the case certify hereby that _______________ whose signature is given above is suffering from __________________ and I consider that a period of absence from duty of ____________________ with effect from __________________ is absolutely necessary for the restoration of his health.


I, Dr. ________________________ after careful examination of the case certify hereby that ______________________ on restoration of health is now fit to join service.

Place ___________________ Signature of Medical attendant.
Date ________________Registration No. ___________________


(Medical Council of India / State Medical Council of ……….....…. State)


Note:- The nature and probable duration of the illness should also be specified . This certificate must be accompanied by a brief resume of the case giving the nature of the illness, its symptoms, causes and duration. 

Source:http://www.mciindia.org/RulesandRegulations/CodeofMedicalEthicsRegulations2002.aspx