Accommodation Request: Health Care Provider Form

Confidentiality - Collection, use and disclosure of this information is subject to all applicable privacy legislation.

TO BE COMPLETED BY STUDENT - CONSENT TO RELEASE INFORMATION

I_____________________________(print name) hereby authorize this health practitioner to
provide the following information to de Souza Institute, and, if required, to supply
additional information, relating to the provision of my academic accommodations. I also authorize de Souza Institutes to contact the above health care provider to discuss the provision of accommodations.

Draw your signature into the box below.

Draw or Type

I understand this is a legal representation of my signature. Clear

Full Name

I understand this is a legal representation of my signature.
/ MM / DD YYYY

I understand this is a legal representation of my signature.
To be Completed by Health Care Provider

Confidentiality - Collection, use and disclosure of this information is subject to all applicable privacy legislation.
I have known I have known First Last
Since Since / MM / DD YYYY
In my Capacity as a (Professional Title)
Briefly describe the condition/disability/disorder including date of diagnosis that necessitates a request for academic accommodation for a course or an exam and why accommodation is required
Maximum of 1000 characters allowed. Currently Entered: 0 characters.
Is this condition permanent or temporary?

Is this condition permanent or temporary? Permanent Temporary
If temporary, please estimate return to condition/disability/disorder status If temporary, please estimate return to condition/disability/disorder status / MM / DD YYYY
Health Care Provider Contact Information

This is the description of your section break.
Name Name First Last
Professional Designation
Registration #
Address Address
Street Address Address Line 2 City State / Province / Region Postal / Zip Code Country
Draw your signature into the box below.

Draw or Type

I understand this is a legal representation of my signature. Clear

Full Name

I understand this is a legal representation of my signature.
Date Date / MM / DD YYYY
Thank you

Please submit the completed form, along with any additional information, to: Confidential Fax: +1 (855) 712-0826 or email to support@desouzainstitute.com
If you have any further inquires you can contact us at 416-581-7887

Accommodation Request: Health Care Provider Form

Accommodation Request: Health Care Provider Form

To be Completed by Health Care Provider

Health Care Provider Contact Information

Thank you Please submit the completed form, along with any additional information, to: Confidential Fax: +1 (855) 712-0826 or email to support@desouzainstitute.com If you have any further inquires you can contact us at 416-581-7887

Thank you

Please submit the completed form, along with any additional information, to: Confidential Fax: +1 (855) 712-0826 or email to support@desouzainstitute.com
If you have any further inquires you can contact us at 416-581-7887