An application for a late ballot must comply with the applicable provisions of Section 84.002 and must include or be accompanied by a certificate of a licensed physician or chiropractor or accredited Christian Science practitioner in substantially the following form:
"This is to certify that I know that __________ has a sickness or physical condition that will prevent him or her from appearing at the polling place for an election to be held on the __________ day of __________, 20___, without a likelihood of needing personal assistance or of injuring his or her health and that the sickness or physical condition originated on or after __________.
"Witness my hand at __________, Texas, this __________ day of __________, 20___.
________________________________
(signature of physician,
chiropractor, or practitioner)"