Student Medical Certificate

STUDENT NUMBER:_____________________Note: The student must submit the original Certificate to the Program Coordinator/Director.

I: TO BE COMPLETED BY STUDENT :

I, __________________________________, hereby authorize this physician to provide the following information to Canadian Therapeutic College relating to my petition for special academic consideration. I understand that the decision on my petition will be made by the Program Coordinator/Director.

SIGNATURE:__________________________________ DATE_______________________

II: TO BE COMPLETED BY PHYSICIAN:

I hereby certify that I provided health care services to ___________________________, a student at Canadian Therapeutic College on [date(s)]

________________________________________________________________.

On the basis of that episode of care, I am providing the following information for use by the College in assessing what special consideration, if any, should be given to this student in respect of missed or affected classes, assignments, tests or examinations.

1.            Time line of the problem: a) Date of onset of problem (or most recent episode if problem is chronic):

b) Expected duration of the problem or most recent episode:

2 Is this an acute or chronic problem for the student? ______________________________

3 The student’s symptoms were subjective, with limited findings: YES NO

4. Student not seen when ill. VERIFICATION BY PHYSICIAN: NAME (please print) ________________________ ADDRESS___________________________

(stamp, business card or letterhead acceptable) REGISTRATION NO. CPSO________________ TELEPHONE NUMBER___________________ DATE __________________________ SIGNATURE __________________________________

NOTE: Any cost for this certificate must be paid by the patient.