Attending Physician'S Statement
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1Student Service Centre
Attending Physician’s Statement
1120 - 2010 12th Avenue
Regina, Canada S4P 0M3
306-787-5620
1-800-597-8278
Fax: 306-787-1608
For Office Use Only
File No.
Student Information
Student’s
Student’s Post Secondary
Full Name: _________________________________________________
Education No.: _______________________________
(please print)
Mailing Address: ____________________________________________________________________________________________
(street/apartment number)
(city/town)
(province)
Postal Code: ________________________________
Telephone: ________________________________________
Note: The Student is responsible for any charge which may be made for completion of this form by the Attending Physician.
This form is not to be used as confirmation of a permanent disability.
Check () the reason for this Attending Physician’s Statement.
Provide medical information to support the assessment/reassessment of my loan application
Verify medical information on my loan application for overpayment investigation
Patient Release of Medical Information
Patient’s
Relationship to Student: Self
Spouse
Full Name: ____________________________________________
Other - Specify: __________________________________
I hereby authorize this information on this form to be released to the Ministry of Advanced Education for official use under
the student assistance programs. I hereby release the attending physician named below of any and all claims for any action
taken by the Ministry of Advanced Education resulting from this statement.
x______________________________________________
______________________________________________
Patient’s signature (in ink)
Date
To be completed by Attending Physician
To the best of your professional judgment, what will be (was) the period of time the above-noted patient will be (was)
medically unfit to perform normal duties such as attending school, working, or actively seeking employment?
From
: _______________
To
:____________
(dd/mmm/yyyy)
(dd/mmm/yyyy)
Remarks
: ___________________________________
(please include any unusual circumstances or special conditions which should be considered)
_____________________________________________________________________________________________________________
________________________________________________
_____________________________________________
(Attending Physician’s name)
(Attending Physician’s telephone no.)
Attending Physician’s Mailing Address
: __________________________________________________________
(including postal code)
x______________________________________________
______________________________________________
Attending Physician’s Signature (in ink)
Date
RETURN COMPLETED FORM TO STUDENT
saskatchewan.ca/studentloans | 1-800-597-8278
FS076 03/14
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