Neftaly Medical Certificate
Medical Examination & Patient Satisfaction Report
(Confidential Medical Document)
Patient Information
- Full Name: _______________________________
- Date of Birth: ____ / ____ / ______
- ID / Passport Number: ___________________
- Gender: ☐ Male ☐ Female ☐ Other
- Contact Number: _________________________
- Address: ________________________________
Medical Examination Details
- Date of Examination: ____ / ____ / ______
- Place of Examination: ____________________
- Attending Medical Practitioner: Dr. _____________________
- Medical Registration Number: _______________
Reason for Medical Examination:
☐ Routine Check-up
☐ Pre-employment Screening
☐ Fitness for Duty
☐ Return to Work Assessment
☐ Other: ___________________________
Summary of Findings:
(Include relevant observations such as vital signs, physical findings, lab tests, etc.)
Diagnosis (if applicable):
Recommendations:
☐ Fit for Work/Study
☐ Unfit for Work/Study (until //____)
☐ Requires Specialist Referral
☐ Follow-up Required
☐ Other: ________________________________
Patient Satisfaction Assessment
To ensure the highest standard of care, we assess patient satisfaction during each consultation. Based on today’s visit:
- Did the doctor explain the examination clearly?
☐ Yes ☐ No ☐ Partially - Was the staff courteous and professional?
☐ Yes ☐ No - Was your privacy and dignity respected during the examination?
☐ Yes ☐ No - How satisfied are you with the service provided?
☐ Very Satisfied ☐ Satisfied ☐ Neutral ☐ Dissatisfied ☐ Very Dissatisfied - Additional comments from patient (if any):
Medical Practitioner Declaration:
I hereby certify that I have conducted a medical examination on the above-mentioned individual and provided relevant findings, advice, and care in accordance with medical ethics and professional standards.
Signature of Practitioner: ___________________________
Date: ____ / ____ / ______
Patient Declaration:
I acknowledge that I have received a medical examination and provided feedback regarding my satisfaction with the consultation. I understand that this document is confidential and intended solely for verification purposes.
Signature of Patient: ___________________________
Date: ____ / ____ / ______
Neftaly Healthcare Services
Professional. Ethical. Trusted.
Contact: [Insert Contact Details]
Website: [Insert Website]