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英文紹介状サンプル(ヤンヒーモデル)  

事例 「他院で診断とホルモン治療を受け続けていたものの、海外での SRS を受けるにあたり英
文診断書の発行を断られた」というケースにおける紹介状例

Medical Reference Letter
(ご 紹 介 状 ) 
SAMPLE
To the physician of Yanhee Hospital whom it may concern,
ヤンヒー病院ご担当医 殿
Mr. SAMPLE NAME visited my clinic for seeking GID diagnosis. He was diagnosised and treated
for about SAMPLE years since SAMPLE years old at other clinic(s)  concerning to GID. He was
sufficiently treated by SAMPLE MEDICINE injection as Japanese standard and adequate hormon
replacement therapy under the close supervision of a physician of the clinic(s) who mainly
concerned him from the start of treatment history.
When Mr. SAMPLE NAME seeks medical care for your clinic/hospital, please take a good care of
him. If you have any questions concerning Mr. SAMPLE NAME, feel free to call/send fax or Email to the numbers shown below. サンプルネーム 氏が貴院に受診されました際は、最大限のケアをお願
いします。同氏について何らかのお問い合わせがある際は、下記の当院連絡先までお問合せください。

Yours sincerely,
敬具

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.

このサンプルの文面は架空の特定のケースに即して作成されたものであり、こ
の文面を剽窃して文書を作成して宛先海外医療機関に提出すると、不適正
条件に該当するとしてSRSを拒否されますのでご注意ください。さらに、実際
には各宛先医療機関ごとの様式要件と記載事項要件があります。
英文紹介状サンプル(ヤンヒーモデル)  
事例 「他院で診断とホルモン治療を受け続けていたものの、海外での SRS を受けるにあたり英文診断書の発行を断られた」というケースにおける
紹介状例