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sample template for health practitioner's letter

This is a template letter for your doctor to write. This can be a GP or a gender specialist. You do not have to have started medical transition to receive this letter. It should be on headed paper with the name and address of the person who is writing it.

Medical Reference No. xxxxxxxxxxxxx Date.

To whom it may concern,

This is to confirm that my patient [Full name] has been diagnosed as having gender dysphoria and is currently undergoing gender reassignment. This change is to be permanent. As part of this process they have changed their name by Statutory Declaration from [Old full name] to [full name].

Your assistance in making the relevant changes to your records and in preserving full confidentiality would be appreciated.

Doctor, GP or Consultants signature


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