EnglishMedicalCertificateTemplatedocx
EnglishMedicalCertificateTemplatedocx
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  1. MEDICAL CERTIFICATEThis is to certify that medical checkup of <Mr. / Ms.>[NAME](Passport No. [PASSPORTNUMBER]), whose signature is given below, that was conducted on [DATE1], showedher badly crooked teeth may have negative influence on her health and orthodontic treatment is necessary for the improvement of her health and the treatment is conducted every month since [DATE2]. The treatment is not an aesthetic purpose.Name of Applicant: [NAME]Passport No.: [PASSPORTNUMBER]Date of Birth: [DATE3]Signature of Applicant:Signature of Doctor:Stamp of Doctor’s Clinic:Issued Date:[DATE4]※当テキスト画像は発行前に削除してください。文言は適宜修正してご使用ください。記入・修正項目リスト<Mr. / Ms.>:男性/ 女性を選択[NAME] : 名前を記入[PASSPORTNUMBER] : パスポート番号を記入[DATE1] : 診断(カウンセリング)日を記入[DATE2] : 治療開始日を記入[DATE3] : 自分の誕生日を記入[DATE4] : 発行日を記入Signature of Applicant: 自分のサインを手書きで記入Signature of Doctore: 担当医のサインを手書きで記入Stamp of Doctor’s Clinic : 歯科医院のスタンプを押す
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