Emergency Certificate
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NAME OF THE HOSPITAL
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PLACE OF THE HOSPITAL
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EMERGENCY CERTIFICATE
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          This is to certify that Mr./Mrs./Miss. ________________ _______________________Mother/Father/Husband/Wife/Son/ Daughter of Mr./Mrs./Miss.___________________________ aged________years was admitted in our _________________ _______________hospital on ___________ at ______am/pm in an Emergency Condition Under Dr. ____________________ _________.
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The provisional diagnosis is ___________________________ _________________________________________________.
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He/ She has been discharged on _______________________ at ____________am/pm. His/Her adimission is Emergency.
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Signature and Designation of the Medical Officer In Charge of the Hospital
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EMERGENCY