NAME & ADDRESS OF THE INSTITUTE / HOSPITAL ISSUING THE CERTIFICATE

Certificate No.
Date

CERTIFICATE FOR THE PERSONS WITH DISABILITIES

This is to certify that Shri/Smt./Kum/wife/daughter of Shri __________________________ Age ______________old male/female, Registration No. ______________________________ is a case of physically disabled/visual disabled/speech & hearing disabled and has ____________ % (____________________) permanent (physical impairment/visual impairment/speech & hearing impairment) in relation to his/her ____________________________________________________

Note: -

1. This condition is progressive/non-progressive/likely to improve/not likely to improve. *
2. Re-assessment is not recommended/is recommended after a period of ____________________ months/years.

Sd/- (DOCTOR) Seal

Sd/- (DOCTOR) Seal

Sd/- (DOCTOR) Seal

Signature/Thumb impression
Of the patient

Countersigned by the
Medical Superintendent/CMO/Head of
Hospital (with seal)