Medical Certificate

The undersigned ________________________________, a Surgeon Physician legally

authorized to practice his profession.

Certifies
That having practiced medical examination to ______________________________________

________________________________ of sex _______________________of ______________ years of age. He

is in ____________ state of health so it is considered ________________forthe recreational
activities desired by the interested party.

TA:________________ FC:_______________ FR:______________ TEMP:______________

WEIGHT:___________ SIZE:_____________

Allergies: __________________

Enfermedades que padece y medicamentos que se administran

___________________________________________________________________________________________________
_____________________________________________________________________________________________

Blood type: __________ RH: _________

This certificate is issued for the purposes that may be convenient for the interested
party, in the municipality of Puebla, Puebla on the days of ___________ of the month of
________________________ of 2014.

________________________________ ________________________________

Physician's name and signature Patient's name and signature

Cédula profesional_____________