APLICATION
Last Name:         *
Name:                 *
Fathers name:      *

To:
General Hospital «Asklipieio Voulas»

I ask:
To grant me a certificate to state:

  1. The time of my nursing
  2. The diagnosis of my illness
  3. The state of my health
  4. time of my recuperation
    (possible permit)
Mothers name:     *
Husband name:
Location:             *
Address Number:*
Phone number:     *
E-Mail:                *
 
 
 
 
Α. Case - Hospitalization
 From date:
 To date :
  In Clinic:
  Attending physician
 

B. Case - Emergency Department

 On:
  In Department:

 
 This certificate will be used to:
 
          
Send a copy of this form to my email as well. Felds with star * are obligatory