It could be anything.
I would suggest:
Try and find the Dr. that signed.
Locate application KCVA 112097/83.
Even contact Coast Provincial General Hospital.
The person completing the form appears to be left handed. You could try and determine who completed the form.
Other than that, you could be looking at anything.
I realize it doesn’t prove (or disprove) anything but the Coast Provincial General Hospital exists. I found it on Google Earth at 4°05’20.28” S and 39°39’38.35”E.