Parents/Guardians seeking medical care assistance for their child must download this form
and have the child's doctor retype it on the doctor's letterhead. A copy of this document must be submitted to ICMF and the original must be handcarried with patient on airline(s). Questions? Email: ICMFHOPE@Aol.Com
TO WHOM IT MAY CONCERN:
Date: ____________ Patient's Name: ___________________________DOB: ____________
Patient's Address: ____________________________________________________________
I certify that I am the attending Physician for the above referenced since _____________. I certify that ________________ does not carry any communicable diseases and his/her innoculations are up to date.
(Signature)
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