CONTAGIOUS DISEASE CERTIFICATION 116

VARIETY CHILDREN & FAMILY SERVICES INC

CONTAGIOUS DISEASE CERTIFICATION
Example : HIV-Aids/ TB/ UTI

CONTAGIOUS DISEASE CERTIFICATION

Name

First

Last

D.O.B

Phone #:

Case #:

AGENCY ADMISSION # ( Foster Child Only

This is to certify that the above named patient/child

was examined by me on this

day of

HIV-Aids Test :

Positive

Negative

TB Test

Positive

Negative

UTI Test

Positive

Negative

Note: If further test is necessary, it must be indicated for further for further medical attention

Doctor Name

First

Last

Phone Number

Signature MD

Date :

Time :

Name of Medical Clinic:

Laboratory Test Contacts: Ramesh Pamnani. 076 640420/ 077 787980 Pursuant to the child protection Laws of Sierra Leone, any falsification of this test results is a crime and may result in legal and professional prosecution.

Address :

VCFS0086/12-14/R – 4/2017

If you are human, leave this field blank.

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