Medical Attestation

Medical Attestation

To be completed by the student's treating physician, psychiatrist, psychologist, or similar.
Healthcare Provider Details
Your name*

PrefixFirstLast
Your title*
Your email address*
Your phone number*
Format: (000) 000-0000.
Your practice/office address*

Street Address 1

Street Address 2

CityState

Zip CodeCountry
Student Details
Student name (the patient)*

First NameLast Name
What is the student's medical diagnosis or condition?*
Approximate date of onset*
Please describe the symptoms, nature, and severity of the student's medical condition that significantly impact the student’s ability to participate in their study abroad program (academically or otherwise).*
Please describe your recommendations for accommodations to the student's academic and/or non-academic activities.*
Please provide an approximate timeline for these accommodations.*
Additional comments
Your signature*

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Healthcare Provider Details