Medical Evidence for Students

Address: *

School of Studies: *

Named GP (if known):

Please specify below (please tick at least one box):

Disability Advice/DSA applications

Exceptional Circumstances (performance impairment/late or non submission)

Non-attendance – exams

Housing evidence

Study Abroad evidence

Teaching/Social/work placement

Medical school report

Fitness to study/fitness to return

Additional Information:

Dates affected from: *

Dates affected to: *

Patients’ Comments:

Reference:

This reference should have been given to you in a text message. If you have not received a text, just put N/A.

*

I give my consent for the Doctor/Nurse to provide details of my period of ill health to the University of Sussex.

Date:

Tell us whether you accept cookies