Marius Scheepers and Company
Attorneys
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Form Y - Medical Certificate
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Name of practitioner : ____________________________________________ Address : _________________________________________________________ Qualifications : __________________________________________________ Name of patient :__________________________________________________ Employment number (if applicable) : ______________________________ Date of examination : ___________________ Time : __________ This certificate is issued after personal observation / during an examination / from information supplied by the patient (based on accepted medical grounds). Description of disease, ailment or disorder: ___________________________________________________________________ ___________________________________________________________________ (only after the patient had authorised that such information may be released in terms of the patient's written authority that is included hereunder). The patient is totally unfit for normal duties / able to do less strenuous tasks. Time of issue of certificate: _______________________________________ Signed: __________________ I declare that I hereby approve that the Medical Practitioner discloses my Medical Condition (Description of disease, ailment or disorder). Signed:________________________________ Remarks: _____________________________________________________ |
Compiled by M. Scheepers
This manual is copyright under the Berne Convention. In terms of the Copyright Act, No. 98 of 1978, no part of this manual may be reproduced or transmitted in any form or by any means, electronic or mechanical, including photocopying, recording or by any information storage and retrieval system, without permission in writing from the author.
