Free template for clinics
Medical certificate template
A printable medical certificate form for clinics and licensed physicians. Fill in the clinic, patient, and examination details and print or save as PDF - or clear the fields and print blank forms to keep in the consulting room.
A medical certificate can only be issued by a licensed physician for a patient they have examined. This is a blank form for that physician to complete and sign - it certifies nothing on its own.
Clinic
Patient
Examination
Attending physician
Nothing you type here leaves your browser - there is no account, and the form is not sent anywhere. Clear the fields and print to get a blank version you can fill in by hand.
San Roque Family Clinic
31 Bonifacio Street, Iloilo City
(033) 555 0121
MEDICAL CERTIFICATE
No. MC-0429 Date issued
This is to certify that
Age Sex
Address
was examined on
Findings and remarks
Advised rest / unfit for duty from to
Issued upon request of the patient for the purpose of
PRC Licence No.
Attending physician
This certificate is valid only when completed and signed by the attending licensed physician named above, and relates solely to the examination carried out on the date stated.
The fields clinics most often leave off
The certificate itself is a short document, which is exactly why the omissions are easy to miss until an employer or an insurer sends one back.
The most common is the date of examination. Clinics print the issue date and stop, but the two are frequently different - a patient seen on Monday may collect the certificate on Wednesday - and the examination date is the one that establishes what was actually observed and when. Both belong on the form.
The second is the licence number. A certificate is a professional attestation, and without the physician's registration number on its face it is difficult for anyone receiving it to verify who issued it. It sits directly under the signature on this form for that reason.
The third is a stated purpose and, where relevant, explicit rest dates. "Unfit for duty" with no dates invites the recipient to interpret it, and they will interpret it in whichever direction suits them. Naming the period removes the ambiguity.
One point on confidentiality: many employers need only a statement of fitness and the dates, not a diagnosis. Disclosing no more than the stated purpose requires is generally the better practice, and it is the examining physician's judgement to make rather than a form's.
Common questions
What should a medical certificate contain?
The issuing clinic and its contact details, a certificate number and date of issue, the patient's name, age and address, the date the patient was actually examined, the physician's findings, any period of recommended rest or unfitness for duty, the purpose it was requested for, and the attending physician's name, signature, and licence number. The examination date matters as much as the issue date - they are not always the same day.
Who can issue a medical certificate?
Only a physician licensed to practise in the relevant jurisdiction, and only for a patient they have actually examined. The certificate is a professional attestation carrying the physician's licence number, which is why this template puts that number on the face of the document and states that it is valid only once signed.
What details go in the findings section?
Whatever the examining physician determines is clinically relevant and appropriate to disclose for the stated purpose. Many employers need only a statement of fitness or unfitness for duty and the dates involved, not a diagnosis - sharing no more than the purpose requires is generally the better practice for patient confidentiality.
How long is a medical certificate valid?
It attests to an examination on a specific date, so it does not expire so much as become historical. Where it covers a period of rest or unfitness, that period is stated explicitly on the certificate. Organisations often decline certificates issued long after the absence they cover.
What is the PRC licence number on the form?
In the Philippines, the Professional Regulation Commission licence number identifies the physician as registered to practise. A PTR number, issued by the local government where the practitioner pays their professional tax, is often included alongside it. Outside the Philippines, substitute whichever registration number your regulator issues.
Can I use this template in my clinic?
Yes, and it is free to use commercially. Fill it in and print, or clear every field and print blank forms to keep in the consulting room. Nothing you type is transmitted anywhere - the form runs entirely in your browser.
When certificates are one part of the record
A printed form is fine for occasional requests. The friction shows up when a patient asks for a copy of something issued months ago and it lives in a folder rather than against their record. Smapey's clinic manager keeps patient records, appointments, and visit history together, with a scheduling side for the consultations themselves.
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