精神科医のための海外渡航時の薬剤（携行）証明書の書き方（サンプル付）

Medication (Carrying) Certificate (Sample)

To Whom It May Concern,

This is to certify the following information:

• Patient Name: Mr./Ms. [Patient Name (ローマ字)]
• Date of Birth: [Date of Birth]
• Diagnosis: [Diagnosis（診断名）]

The above patient is currently under my medical care and requires ongoing treatment with the medications listed below:

The following medications have been prescribed:

1. Sertraline (Zoloft)
   • Dosage: 50 mg/day
   • Administration: once daily in the evening
   • Prescription Period: From [Start Date] to [End Date]
2. Brotizolam（Lendormin）
   • Dosage: 0.25 mg/day
   • Administration: once daily before bedtime
   • Prescription Period: From [Start Date] to [End Date]
3. : Lorazepam (Wypax)
   • Dosage mg/day
   • Administration: as needed for anxiety, up to twice daily
   • Prescription Period: From [Start Date] to [End Date]

Physician: [Physician’s Name]
Institution: [Name of Medical Institution]
Address: [Institution Address]
Contact: [Telephone number]
Signature: ______________________________
Date: [Date]