Victorian Numbered Regulations

MARINE REGULATIONS 2009 (SR NO 180 OF 2009) - SCHEDULE 9

SCHEDULE 9

Sch. 9

Regulation 505

CERTIFICATE BY MEDICAL PRACTITIONER TAKING BLOOD SAMPLE

I [ insert name of medical practitioner ], a medical practitioner registered under the Health Professions Registration Act 2005 , certify that the sample of blood described below was taken in accordance with the requirements of the Marine Regulations 2009.

Name of the person from whom the blood sample was taken:

Time that the blood sample was taken:

Date that the blood sample was taken:

Name of the medical practitioner who took the sample:

Signature of the medical practitioner who took the sample:

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