MEDICAL ATTESTATION REPORT

INSTRUCTION:
1.
2.
3.

This form is only applicable to application for special consideration for replacement of examination on medical
grounds.
Please enclose original copy of the medical certificate to be submitted to the respective course within five (5)
calendar days inclusive of the examination day.
Students are required to complete Section 1 and Medical Practitioner to complete Section 2 (with the providers
stamp affixed).

SECTION 1: Student / Patient Details

Student Name :______________________________________________Student ID : _____________________________
Course(s) Name : ____________________________________________ Course(s) Code : _________________________
Date of Examination Missed : __________________________________
I authorize UCSI to contact the medical practitioner to provide further details to UCSI in order to discuss and verify the
implications of the illness/condition of which I am suffering.
Signature : __________________________________________________ Date : _______________________________

SECTION 2 : Medical Practitioner

Attending Practitioner : _________________________________Date & Time Examined : ________________________
Chief Complaint / Diagnosis : _________________________________________________________________________
_________________________________________________________________________________________________
Medications Prescribed : _____________________________________________________________________________
_________________________________________________________________________________________________
Date(s) for which MC was granted : From _________________________to ____________________________________
Will the nature of the illness/medication prevent the patient from appearing for the examination?
(
) YES
(
) NO
If yes, please specify why : ______________________________________________________________________________
___________________________________________________________________________________________________

Signature of Practitioner & Stamp : _________________________________ Date : _______________________________

For office use :

Faculty
Received by
Staff Name : ______________________
Signature : ________________________
Date : ____________________________

Decision / Remarks :
_________________________________________________________________________________________
_________________________________________________________________________________________
_________________________________________________________________________________________
_________________________________________________________________________________________
_________________________________________________________________________________________