Government of India
DR.RAM MANOHAR LOHIA HOSPITAL
SAFDARJUNG HOSPITAL
ALL INDIA INSTITUTE OF MEDICAL SCEINCES
(Please Strike out whichever is not applicable)
DR.RAM MANOHAR LOHIA HOSPITAL
SAFDARJUNG HOSPITAL
ALL INDIA INSTITUTE OF MEDICAL SCEINCES
(Please Strike out whichever is not applicable)
No.
Date :
1) General Observations :
This is to certify that
Ms/Mrs/Mr................................................aged.........years,
Male/Female, son / daughter / wife / husband / father / mother /
brother / sister / mother or father-in-law of
Ms/Mrs/Mr....................................is a diagnosed case of
...............................................................and is
undergoing treatment in the department of
.............................of this Hospital
since..............................
2) Specific recommendation :
(i) Detailed description of illness/disability alongwith investigations, if any:
(ii) Is the disability permanent or likely to improve with time.
(iii) Class/stage of disease/percentage/grade of functional disability inspite of optimum treatment and intervention.
(iv) Is the ailment/disability serious enough to be considered for
allotment or change of Govt. Accommodation at any/Ground Floor on
overriding priority:
Signature of patient/Guardian }
Alongwith Attested Photograph}
Note: Physical disability certificates issued by single doctor in
pursuance of Guidelines No.S-13020/1/2012-MS/MH-II of Directorate
General of Health Services (Medical Hospital Section-II), Nirman Bhawan,
dated 18.6.2010 is also acceptable.
Signatures of Members of Board alongwith rubber-stamp/date :
(Member)
(Seal with Name) |
(Member)
(Seal with Name) |
(Member)
(Seal with Name) |
---|
(Medical Superintendent)
(Seal with Name)
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