Medical documentation
Form # 095-У
STAMP
Ministry of health of Ukraine
Outpatients’ clinic
Central regional hospital
Certificate # 1
Of temporary disability of a student or of illness, quarantine and other reasons of a child’s absence in school or preschool educational establishment.
Outpatients’ clinic of Ostroh
Date of issue: —-
Name of educational establishment: —.
First name, last name, patronymic: —
Year of birth: —
Diagnosis: acute respiratory disease
Contact with infected patients (yes, no, which exactly): ___
Complicated by bronchitis
From – till —
From – till –
Round seal of Outpatients’ clinic
Round seal of a doctor
Signature
Head of Central regional hospital Signature