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Date No.

No., Rank and Name

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Signature of M.O.

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or Military Hospital.

C.A.F.C. 680
2M pads of 100—5-51 (4733)
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(PTace)

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Name ,

Service No,

Address. . .

(1) Medical examination indicates that 3'-^ou require troa-^.mcnt,

(2) li is necessary to defer your treatment until,...,,......, ,....

on which date you 'vill repor t to ...,,,..... .

(3) EJrecti\ . the o ate of admi.'^sion to treatment, you ^o'l;'' be o.-^ct. t

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discharge.

for District Administrator, D.'^KA

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(Detach griginal,_fo_r_yet.jran)

Information for District and Head Office use.

Date of Discharge,
Date ro^-jorted to D.V.A,

Diagnosis on Discharge , .
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Other medic:! evidence indicating condition prcs.:nt at time of discharge., ,.

Reason for Deformcnt (indicate oy "X'' in appropri: te square)

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For Head Office Use

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Datr for D.G.T.S,
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Date for D.G.T.S.
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REPORT FOR
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(Place)

(Pate)
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Service No<

Address. . .

(1) Medical examination indicates that jou require treatment,

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on v/hich date you "vill report to, , ,

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with pay and alloi^ances oquivalt. it tc those issuer^ to you ?mmcdiatjJ ^xio" j yo.
discharge.

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Information for District and Head Office use.

Date of Discharge......
Date reported to D-V.A,

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Other medic:l evidence Indicating condition prcs.:nt at time of discharge.

Reason for Deferment (indicate oy "X" ^^ ap-ofopriate square)

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t::::::L (2) Medical judgment du_ to veterans condition. E:-qDlain ful""

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For Head Office Use

Approved
Drto for D.G.T.S,

Not Approved
/ Date for D.G.T.S,

Upper half, of original to veteran

Duplicate to Hc-.ad" Office
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