ESSENTIALITY CERTIFICATE - A Certificate granted to Mr/Mrs/Miss____________________________ wife/son/daughter of Mr_____________________________ employed in the __________________________________________________________. CERTIFICATE - A I Dr._________________________________________ hereby certify (a) that I charged and received Rs.________ (Rupees__________________ ____________________________________) only for consultations (dates to be given) at my consultations room/at the residence of the patient. (b) that I charged and received Rs.__________ (Rupees_________________ ____________________________________) only for administering _____________________________________at my consultations room / at the residence of the patient. (c) that the injections administered were not for immunizing or prophylactic purpose. (d) that the patient has been under treatment at ___________________________________hospital ___________________ and that the under mentioned hospital medicines in my consulting room prescribed by me in this connection were essential for the recover / prevention of serious deterioration in the condition of the patient. The medicines are not stocked in the ________________________________ (name of the hospital), do not include preparations for which cheaper substances of equal there pubic value are available not preparation which are primarily foods, toilets or disinfections. Name of Medicines Price Name of Medicines Price Contd.p/2. -2- (e) that the patient is/was suffering from _____________________________ and is /was under my treatment from ___________________ to __________ (f) that the patient is/was not given pre-natal or post-natal treatment. (g) that the X-ray, laboratory test etc. for which an expenditure of Rs._____________ (Rupees _____________________________________) only was incurred / was necessary and were under taken or my advice at __________________________________________ (name of the hospital or laboratory). (h) that I referred the patient to Dr._________________________________ for specialist consultation and that the necessary approval of the _______________________________________ 9name of the Chief Administrative Officer of the State) as required under the rules was obtained. (i) that the patient did not require/required hospitalization. Date : Signature & Designation of the Medical Officer and hospital / Dispensary to which attached.
