Avaa tulostettava versio tästä:

Medical certificate for carrying of medication and utensils

Patient's name:. . . . . . . . . . . . . . . . .

Date of birth:. . . . . . . . . . . . . . . . . .

This is to certify that the above named person carries the following medications and utensils, which are for personal use in the treatment of the medical conditions mentioned

Medical condition(s): . . . . . . . . . . . . . . .

. . . . . . . . . . . . . . . . . . . . . .

Medication(s) (generic names) and utensils: . . . . . . .

. . . . . . . . . . . . . . . . . . . . . .

Syringes: . . . . . . . . . . . . . . . . . . .

Needles:. . . . . . . . . . . . . . . . . . . .

Other utensils:. . . . . . . . . . . . . . . . . .

Date. . . . . . . . . . . . . . . . . . . Official stamp

Physician's signature: . . . . . . . . . . . . . . . .