Medical Certificate Format

Form No. I
STERILISATION CERTIFICATE

I, Dr. hereby certify that I have conducted operation on Shri/Smt. husband/wife of Shri/Smt. employed as in at on .

2. A sperm count was undertaken on and on the basis thereof it is certified that the Vasectomy Operation has been completely successful.
* (Para 2 in the case of Vasectomy operations only)
* Delete words where not applicable.

Form No. II
UNDERTAKING TO BE GIVEN BY ALL GOVERNMENT EMPLOYEES

I/My spouse have/has undergone Vasectomy/Tubectomy operation at on . Necessary sterilisation certificate issued by is enclosed. In case I/my spouse have to take resort to recanalisation for any reason whatsoever I undertake to report this fact forthwith to the Government.

2. I also certify that my wife Smt. is not pregnant on this date.
* (Para 2 for male Government employees only)
ರಚನೆ: ಮನೋಹರ್ ಆರ್‌ ಕೆ.ಜಿ.ಎಫ್
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