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ESSENTIALITY CERTIFICATE CERTFICATE A (To be completed in the case of patients who a e N!T A"#ITTE" to hospital fo t eatment$ Certificate granted to Mrs./Mr./Miss.. Wife/Son/Daughter of MR/MRS/MISS ................................ employed in I% " & ........................ hereby certify: !a" !b" that I charged and recei#ed Rs& ... for ..... consultations on ................ !dates to be gi#en" at my consulting room/ at the residence of the patient$ that I charged and recei#ed Rs......... for administering .. intra #enous/intra muscular/subcutaneous in%ections on......!dates to be gi#en" at....................... my consulting Room/the residence of the patient$ !c" !d" that the in%ections administered &ere not/&ere for immunising or prophylactic purposes$ that the patient has been under treatment at . ...................... hospital/ my consulting room and that the undermentioned medicines prescribed by me in this connection &ere essential for the reco#ery/ pre#ention of serious deterioration in the condition of the patient. 'he medicines are not stoc(ed in the .............................. !name of the hospital" for supply to pri#ate patients and do not include proprietary preparations for &hich cheaper substances of e)ual therapeutic #alue are a#ailable nor preparations &hich are primarily food* toilets or disinfectants. Name ' ice + ,. -. ..
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medicines

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that

the patient is/&as suffering f om ............... and is/&as under my treatment f om &&&&&&(&&&&&&&&& to &&&((&(&&&&&&&&&&-

that the patient is/&as not gi#en pre natal or post natal treatment$ that the / ray laboratory test* etc.* for &hich an e0penditure of Rs . .... &as incurred &as necessary and &ere underta(en on my ad#ice at ......... !name of the hospital or laboratory"$ that I referred the patient to Dr. .................... for S12CI34IS' consultation and that the necessary appro#al of the ................................ !5ame of the Chief 3dministrati#e 6fficer of the State" as re)uired under the rules &as obtained$ that the patient did not re)uire/re)uired hospitalisation.

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Si.nat/ e of A#A*"esi.nation of the #edical office and hospital* dispensa 0 to which attached& "ated,+ ++++++++++ N&1&,+ CERTIFICATES N!T A''LICA1LE S2!3L" 1E STR3C4 !FF& CERTIFICATE (E$ IS C!#'3LS!RY AN" #3ST 1E FILLE" IN 1Y T2E #E"ICAL !FFICER IN ALL CASES.

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