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Health Certification: Office of The Municipal Health Officer

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0% found this document useful (0 votes)

21 views1 page

Health Certification: Office of The Municipal Health Officer

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Myssikeah Dariagan

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Republic of the Philippines

Province of Capiz
MUNICIPALITY OF PANITAN
Telefax No. : (036) 6340-665 Telephone No.: (036)6340-665
Office of the Municipal Health Officer

HEALTH CERTIFICATION
FULLNAME:

AGE/SEX:

ADDRESS:

OCCUPATION:

DESTINATION:

REASON:

VALID FOR 3 DAYS ONLY

YES/NO: History of travel to countries/areas with local transmission in the past 14 days.

YES/NO: Expose to COVID (+) patient in the past 14 days.

YES/NO: Symptoms (fever, cough, shortness of breath, sore throat)
YES/NO: COVID-19 Testing (RT-PCR/RDT) performed:
DATE: RESULT:

REMARKS:

This is to certify that this person is neither classified as PUM, COVID-19 suspect, Probable nor
Confirmed case based on DOH Guidelines.
Issued this day of , 2021.

ROSINE DELFIN-AVELINO, M.D

Municipal Health Officer
License No. 0062347

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Health Certification: Office of The Municipal Health Officer

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Health Certification: Office of The Municipal Health Officer

Uploaded by

Republic of the Philippines

VALID FOR 3 DAYS ONLY

YES/NO: Expose to COVID (+) patient in the past 14 days.

ROSINE DELFIN-AVELINO, M.D

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