Uttar Pradesh Rural Road Development Agency

Department of Rural Development Government of uttar pradesh

CERTIFICATE ‘A’

(To be completed in the case of patients who are not admitted to Hospital for treatment.)

Certificate granted to Mrs./Mr./Miss __________________________ Wife/Son/Daughter of Mr. ___________________________ employed in the office of the ___________________________

I, Dr. ___________________________, hereby certify,

That I charged and received Rs. _____________ for _____________ consultations on ________________________ (dates to be given) at my consulting room / at the residence or the patients;

That I charged and received Rs. _______________ for administering _______________ intravenous / intra-muscular / subcutaneous injections on ________________ (dates to be given) at ________________ my consulting room / the residence of the patient.

That the injections administered were not / were for immunizing or prophylactic purpose.

That the patient has been under treatment at _______________ hospital / my consulting room and that the under mentioned medicines prescribed by me in this connection were essential for the recovery / prevention of serious deterioration in the condition of the patient. The medicines are not stocked in the ________________ (names of hospitals) for supply to private patient and do not include proprietary preparations for which cheaper substances of equal therapeutic value are available nor preparations which are primarily foods, toilets or disinfectants.

That the patient is / was suffering from __________ and is / was under my treatment from ________________ to ________________

That the patient is / was not given pre-natal or post-natal treatment.

That the X-ray, Laboratory test, etc. for which an expenditure of Rs. ________________ was incurred was necessary and were undertaken on my advice at ___________________________ (name of the Hospital or Laboratory).

That the patient did not require / required hospitalization.

That the ailment is / is not a chronic ailment and medicines at S.No. __________________ above are required for prolonged treatment of the chronic ailment and will need ot be taken for at least __________________ days / 3 months / ________________

Dated