Section I - TO BE COMPLETED BY THE STUDENT. Return completed form to your TA when you write the make-up test.
Physician InformationPhysician’s Name Street Address City Telephone Number Fax Number Province Postal Code Student’s Name Student Number Faculty
Patient’s Name (if other than Student)
Personal healthinformation on this form is collected under the authority of The York University Act, 1965. academic petition to York University.
It is related directly to and needed to support your
Pursuant toS. 29 of PHIPA (Personal Health Information Protection Act), I (the undersigned student or patient) authorize and consent to the physician named on this form to disclose to the York Universityfaculty and administrative staff authorized to administer and consider academic petitions such personal health information as is necessary or as may be reasonably required by York University to support myacademic petition. I understand that York University will maintain and store this information in such a manner as to protect its confidentiality. Signature of Student/Patient (if other thanStudent) Date
Section II - TO BE COMPLETED BY THE ATTENDING PHYSICIAN. The above named student, who is registered at York University, has petitioned for special consideration on medical grounds. Thestudent or patient related to the student is authorizing you, the attending physician, to release the information requested below. Please retain a copy of this form for your files as your office may becontacted to verify that this statement was completed by the attending physician. The original form must be returned to the student for submission with the petition.
1. Date youreceived this form: ____________________________________________________________
_____________________ 2. Consultation Date(s): ____________________________________________________________...