MEDICAL REPORT & DIAGNOSIS VERIFICATION

Name of child _____________________________________________ D.O.B.__________________________

Name of Parent/Guardian_____________________________________ Phone #_________________________

Address of Parent/Guardian___________________________________________________________________

__________________________________________________________________________________________

Medical Examination & Verification (This examination must be completed and signed by a licensed physician or a certified nurse practitioner.)

I, ____________________________________________, certify that on _______________________________

                  name of physician (please print)                                                                                                     date of appointment

I personally examined ________________________________________, who is 18 years old or younger.

                                                                patient’s first and last name (please print) 

On the basis of my examination and all information provided to me, I confirm that he/she is currently

diagnosed with ____________________________________________________________________________. 

current diagnosis

Name of authorized examiner/title (please print) ________________________________________________

Name of Medical Facility____________________________________________________________________

Address of Medical Facility_______________________________________ Phone #____________________

Signature of authorized examiner _________________________________Date_______________________