Requested Document*

Medical Certificate (Initial) FreeMedical Certificate (Succeeding) P500Medical Abstract (P1,500)Recommendation LetterMedical Records (Screening)Medical Records (Post-op)Medical Records (Screening and Postop)

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Date Needed*

Branch*

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Purpose of Request*

For leave of absenceFor reimbursementProof of surgeryFit to WorkPersonal UseFor EmploymentFor Second OpinionOthers

Date of Procedure*

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