This section must be completed by the student at the time of the visit to the health practitioner.

This section must be initialed by the health practitioner.

This section must be completed by the health practitioner.

The health practitioner’s business stamp (not handwritten) must be added manually here.

If this form is used as supporting documentation for a petition, indicate your petition reference number here in the top right corner of the form.

Requests for special academic consideration based on illness or injury will only be considered if this form is filled out completely and accurately.

New Medical Certificate SAMPLE