Fill in the patient and consultation details, then generate the
certificate and receipt preview below.
MEDICAL CERTIFICATION
Certificate No.:DG-2026-0029
Date of Issue:20/02/2026
1. Patient Information:
Full Name:Joshua Itsuki Ohashi
Birthdate:30/04/2014
Nationality:Japan
ID/Passport No.:-
Gender:Male
2. Medical Consultation Details:
Date of Examination:20/02/2026
Place of Examination:Hotel: Emporium Suites Room No.: 4125
3. Medical Findings:
Chief Complaint:Multiple rashes along the body after shower with itching
History / Clinical Findings:
Multiple erythematous, edematous wheals with well-defined
borders, blanchable on pressure, and pruritic.
Diagnosis / ICD-10:Acute Urticaria of unknown etiology
Treatment / Investigation:
☑ Medication:Elomet lotion, CPM
☐ Investigation:
☐ Procedure / Operation:
4. Medical Advice:
☑ Fit to travel
☐ Fit to fly
☐ Fit to work
☐ Advised hospital evaluation
☐ Other
☐ Unfit to travel until
☐ Unfit to fly until
☐ Unfit to work until
5. Remarks (if any):
6. Doctor's Certification:
I hereby certify that I have personally examined and treated the
above patient. The information provided herein is true and accurate
to the best of my medical knowledge.
Physician's Name:Dr.Wirach Wacharakaroon
Signature :
Medical License No :14606
Date :20/02/2026
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This is a digitally issued medical certificate with a valid electronic
signature and verification QR code. No physical stamp is required.
Please scan the QR code to verify issuance through the Doctor2GO
system.
RECEIPT
Certificate No.:DGR-2026-0029
Date of Issue:20/02/2026
Payment Method:☐ Cash ☑ Credit Card ☐ Bank Transfer ☐ Hotel Charge (Room No.
...............)
1. Patient / Payer Information
Full Name:Joshua Itsuki Ohashi
ID/Passport No.:-
Place of Examination:Hotel: Emporium Suites Room No.: 4125
2. Itemized Medical Services
Description
Qty
Unit Price (THB)
Amount (THB)
Doctor Consultation Fee
1
4,500.00
4,500.00
Nursing Fee
0
0.00
0.00
Procedure Fee
0
0.00
0.00
Medication & Supplies
1
1,500.00
1,500.00
Medical Certificate Fee
0
0.00
0.00
Subtotal:
6,000.00
Discount:
0.00
Net Total:
6,000.00
VAT:
0.00
Grand Total:
6,000.00
3. Authorized Signature
Authorized by:
Signature:
Date:20/02/2026
QR
Scan to verify
This is a digitally issued medical certificate with a valid electronic
signature and verification QR code. No physical stamp is required.
Please scan the QR code to verify issuance through the Doctor2GO
system.