______________________________ is a veteran who has a spinal cord injury or disease. His/her diagnosis is: Paraplegia Quadriplegia Brown Sequard Syndrome Cauda Equina Syndrome ALS Multiple Sclerosis (involving the spinal cord) Transverse Myelitis Other (please specify) _______________________________ __________________________ Physician’s Signature __________________________ Physician’s Name __________________________ Physician’s Title ___________________________ Date Signed __________________________ Physician's Phone/Email Physician's Statement Form
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______________________________ is a veteran who has a spinal cord injury or disease.
His/her diagnosis is: Paraplegia QuadriplegiaBrown Sequard SyndromeCauda Equina Syndrome ALSMultiple Sclerosis (involving the spinal cord)Transverse MyelitisOther (please specify) _______________________________
__________________________ Physician’s Signature
__________________________ Physician’s Name
__________________________ Physician’s Title
___________________________ Date Signed
__________________________Physician's Phone/Email
Physician's Statement Form
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