Patients - Application for Medical Certificate

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STEP 1 OF 1

What is your birth sex? *

Male

Female

Are you currently or in the last two months have you taken any medicine (prescribed or not), alternative medicines or recreational drugs? *

NO, I'M NOT

YES, I AM, please specify:

Other than issues mentioned in your below Sick Note details, do you have any other significant medical conditions, illnesses or past surgical procedures?

NO, I'VE NOT

If other, YES please specify:

Reason for Certificate *

Start of Sick Note (YYYY-MM-DD) *

End of Sick Note (YYYY-MM-DD) *

I confirm that I have read and understood this and my answers are fully correct and true. *

I CONFIRM

I DO NOT CONFIRM

Click here to indicate that you have read and agree to the terms presented in the Terms and Conditions agreement. *

I have read and agree to the Terms and Conditions