Circuit Court Forms

FORM 37V

CERTIFICATE OF ENDOCRINOLOGIST OR PSYCHIATRIST (SECTION 12(4) OF THE GENDER RECOGNITION ACT 2015) — APPLICATION FOR REVOCATION OF A GENDER RECOGNITION CERTIFICATE

I .......... of ..........., *[endocrinologist] *[psychiatrist] hereby certify as follows:

1. I have no connection to ........, who ordinarily resides at ....... (“the child”);

2. I have met the child for the purposes of this certificate.

3. I have read the certificate of ......., medical practitioner, and I concur in my medical opinion with that certificate.

Signed ...........

Dated ...........

*delete where appropriate