Circuit Court Forms

FORM 37U

CERTIFICATE OF MEDICAL PRACTITIONER (SECTION 12(4) OF THE GENDER RECOGNITION ACT 2015) — APPLICATION FOR REVOCATION OF A GENDER RECOGNITION CERTIFICATE

I .......... of .........., medical practitioner hereby certify as follows:

1. I am the primary treating medical practitioner of ........, who ordinarily resides at ......... (“the child”);

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

3. In my professional medical opinion

(a) the child has attained a sufficient degree of maturity to make the decision to live in *[his] *[her] original gender for the rest of *[his] *[her] life,

(b) the child is aware of, has considered and fully understands the consequences of that decision,

(c) the child’s decision is freely and independently made without duress or undue influence from another person, and

(d) the child has reversed the transition or ceased transitioning into the gender recognised in the gender recognition certificate which has issued in respect of the child.

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

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

*delete where appropriate