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SRS

Medical Reference Letter

SAMPLE
To the physician of Yanhee Hospital whom it may concern,

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.

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