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SRS

Medical Opinion Statement

SAMPLE
I asked Mr. SAMPLE NAME sufficient adequate questions to evaluate his sexual
identity concerning to GID diagnosis and performed re-confirmation over his intent
to take SRS out of JAPAN and a inclination of taking his life as male for the rest
of life. I am satisfied by his answer about the emphatic belief of himself taking SRS
and the inclination. In my opinion, it is reasonable to perform SRS toward himas
long as it is done out of Japan and Japanese jurisdiction.
Yours sincerely,

SAMPLE

Date:
Signature:

SAMPLE

SAMPLE DOCTOR, MD, PhD


Chief physician,
SAMPLE CLINIC
Disclaimer:
1. This diagnosis is based sololy on oral concultation and his life history statement in his own writing.
2. Japanese regulation including the guidline concerning GID diagnosis and evaluating the appropriateness for
SRS requires additional examination and one more diagnosis by third party physician in addition to this
diagnosis and certificate.
3. No one may not perform SRS surgery based upon this diagnosis and certificate in Japan geograficaly nor in
Japanese jurisdiction legally.

SRS