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DATE:
/
/
HEALTH CERTIFICATE
To Whom It May Concern:
Name:
Date of Birth:
Sex:
Address:
/
/
Age:
JAPAN
This is to certify that the above person has NO abnormalities on following physical
examination and laboratory examinations including:
Chest X-ray:
EKG:
Blood Chemistry:
Urinalysis:
Physician’s Signature:
