Model Doctor's Letter Certifying Applicant's Gender Change (For U.S. Passport or Consular Report of Birth Abroad)

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Licensed Physician’s Letterhead
(including address and telephone number)

I, [PHYSICIAN’S FULL NAME], [PHYSICIAN’S MEDICAL LICENSE OR CERTIFICATE NUMBER], [ISSUING STATE OR COUNTRY OF MEDICAL LICENSE/CERTIFICATE], [DEA REGISTRATION NUMBER OR COMPARABLE FOREIGN DESIGNATION], am the physician of [NAME OF PATIENT], with whom I have a doctor/patient relationship and [WHOM I HAVE TREATED OR WHOSE MEDICAL HISTORY I HAVE REVIEWED AND EVALUATED].

[NAME OF PATIENT] has had appropriate clinical treatment for gender transition to the new gender [MALE OR FEMALE].

[INCLUSION OF ADDITIONAL INFORMATION IS NOT REQUIRED OR RECOMMENDED].


I declare under penalty of perjury under the laws of the United States that the foregoing is true and correct.

Signature of Physician

Typed Name of Physician

Date


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