University Of Cape Town Dp Certificate Form Page 3
ADVERTISEMENT
1
2
3
4UNIVERSITY OF CAPE TOWN
M
E
D
I
C
A
L
C
E
R
T
I
F
I
C
A
T
E
I
N
S
U
P
P
O
R
T
O
F
T
H
E
D
E
F
E
R
R
E
D
E
X
A
M
I
N
I
A
T
I
O
N
S
A
P
P
L
I
C
A
T
I
O
N
M
E
D
I
C
A
L
C
E
R
T
I
F
I
C
A
T
E
I
N
S
U
P
P
O
R
T
O
F
T
H
E
D
E
F
E
R
R
E
D
E
X
A
M
I
N
I
A
T
I
O
N
S
A
P
P
L
I
C
A
T
I
O
N
P
l
e
a
s
e
n
o
t
e
t
h
a
t
t
h
i
s
f
o
r
m
i
s
o
n
l
y
t
o
b
e
c
o
m
p
l
e
t
e
d
i
f
t
h
e
s
t
u
d
e
n
t
i
s
r
e
q
u
e
s
t
i
n
g
a
d
e
f
e
r
m
e
n
t
o
f
a
n
e
x
a
m
i
n
a
t
i
o
n
o
n
P
l
e
a
s
e
n
o
t
e
t
h
a
t
t
h
i
s
f
o
r
m
i
s
o
n
l
y
t
o
b
e
c
o
m
p
l
e
t
e
d
i
f
t
h
e
s
t
u
d
e
n
t
i
s
r
e
q
u
e
s
t
i
n
g
a
d
e
f
e
r
m
e
n
t
o
f
a
n
e
x
a
m
i
n
a
t
i
o
n
o
n
m
m
e
e
d
d
i
i
c
c
a
a
l
l
g
g
r
r
o
o
u
u
n
n
d
d
s
s
.
.
F
F
o
o
r
r
a
a
n
n
y
y
o
o
t
t
h
h
e
e
r
r
r
r
e
e
a
a
s
s
o
o
n
n
t
t
h
h
e
e
d
d
o
o
c
c
u
u
m
m
e
e
n
n
t
t
a
a
t
t
i
i
o
o
n
n
a
a
p
p
p
p
l
l
i
i
c
c
a
a
b
b
l
l
e
e
t
t
o
o
t
t
h
h
e
e
r
r
e
e
a
a
s
s
o
o
n
n
o
o
f
f
d
d
e
e
f
f
e
e
r
r
m
m
e
e
n
n
t
t
m
m
u
u
s
s
t
t
b
b
e
e
s
u
b
m
i
t
t
e
d
w
i
t
h
t
h
e
a
p
p
l
i
c
a
t
i
o
n
f
o
r
m
.
s
u
b
m
i
t
t
e
d
w
i
t
h
t
h
e
a
p
p
l
i
c
a
t
i
o
n
f
o
r
m
.
NOTE: A DOCTOR'S CERTIFICATE IS NOT SUFFICIENT: (this form must be completed)
NB: THIS CONFIDENTIAL REPORT MUST BE COMPLETED BY THE MEDICAL PRACTITIONER
AND FAXED/EMAIL TO: Vanessa Chitter
Fax number: (021)650-5714
email address:
vanessa.chitter@uct.ac.za
The student gives permission to the University to contact the medical practitioner to clarify or amplify any
points in this report. It is expected that the medical practitioner is not related to the student.
SURNAME (student): …………………………..………………… INITIALS: ……………… TITLE: ……..
DATE OF CONSULTATION: ………/…..…/……
(This must be the actual date the doctor saw the patient,
not the date of when the illness started)
DETAILED DESCRIPTION/EXPLANATION OF SYMPTOMS AND/OR HISTORY: (If this is not sufficient
space please attach a separate report)
……………………………………………………………………………………………………………………......
………………………………………………………………………………………………………………………..
RESULTS OF PHYSICAL EXAMINATION:
………………………………………………………………………………………………………………………..
………………………………………………………………………………………………………………………..
DIAGNOSIS AND PRESCRIBED TREATMENT: (Please indicate the seriousness of the ailment/s on a scale
of 1-10: 10 = most serious)
1
2
3
4
5
6
7
8
9
10
(NB: please ring)
Please confirm any conditions (if any) which rendered him/her unfit to write an exam
………………………………………………………………………………………………………………………..
………………………………………………………………………………………………………………………..
If you considered the student is/was unfit to write the exams, please indicate the dates on which the
candidate was considered to be unfit to write the exams:
FROM: …………………………………………… TO: ………………………………………………………….
DOCTOR'S NAME (Please print): ………………………… DOCTOR'S SIGNATURE: ………………………..
ADDRESS: ………………………………………………………………………………………………………….
………………………………………………………………………….TELEPHONE: ………/…………………..
DOCTOR’S STAMP:
NB: Student must give the medical practitioner this confidential report which must be returned separately (ie
directly by the doctor to Vanessa Chitter)
3
ADVERTISEMENT
0 votes
Related Articles
Related forms
Related Categories
Parent category: Business