December 3, 2008
Re: [birth name]
SS# [social security number]
DOB: [birth date]
To Whom It May Concern:
This letter is in regards to my patient whose date of birth is [birth date]. Psychological and medical testing has been carried out to determine this patient’s true gender. In the case of [birth name], this was determined to be male.
Sex reassignment surgery has been completed on November 24, 2008 and [birth name] is not of the sex recorded on the original records.
This letter should qualify [birth name] to be legally considered male within the guidelines of the particular jurisdiction in which this individual seeks to legally change his gender status.
I declare under penalty of perjury under the laws of the state of Ohio that the foregoing is true and correct.
Sincerely,
[signature]
Daniel A. Medalie, MD
Assistant Professor of Plastic Surgery
MetroHealth Hospitals and Case Western Reserve University
phone: [number]
fax: [number]