Medical professional details
Sections 2, 3 and 4 should be completed by a medical professional
To support the student’s DSAs application we need you to give us information
about the nature of the student’s disability. Complete the rest of the form, read,
sign and date the declaration, then pass the form back to the student. As the
student can’t reclaim any charge made for completing this form via DSAs, we ask
that it is provided free of charge.
To find out how we’ll use the information you provide go to
www.gov.uk/studentfinance to read our Privacy Notice before completing
2.1 Your details
Certificate or registration number
(GMC, HCPC, NMC)
2.2 Practice or organisation
Where possible use your
practice or organisation’s
Type of practice or organisation
Primary Care Team
Other (give details below)
Name of practice or organisation
2.3 What is your professional
involvement with the student?
You only need to give details if this
isn’t apparent from your job title.