Sample Doctor's Letter for Gender Marker Change

[This letter must be copied on licensed physician’s letterhead, including physician’s address and
telephone number. The letter must be from a licensed Medical Doctor (MD) or Doctor of
Osteopathy (DO)]

I, [Physician’s Full Name], am the physician of [Name of Patient], with whom I have a
doctor/patient relationship and whom I have treated [or with whom I have a Doctor/Patient
relationship and whose medical history I have reviewed and evaluated].

[Name of Patient] had surgery for gender confirmation on [date of procedure] and has undergone
irreversible changes to the new gender of [Male/Female]. [Name of Patient]’s identity documents
should reflect [his/her] correctly gender of [Male/Female].

I declare under penalty of perjury under the laws of the United States [and State if applicable],
that the foregoing is true and correct.

[Signature of Physician (must be an original and not photocopy)]
[Typed name of Physician]
[Issuing U.S. State/Foreign Country of medical license/certificate & Physician’s medical license
or certificate number]
[Date]

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