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Medical Letters & Certificates Request Form

Type of document requested

Product

Personal details

Date of Birth
Day
Month
Year

Request overview

Purpose / reason 

  • e.g., “work absence”, “workplace adjustments”, “university extenuating circumstances”, “travel cancellation” etc.

Current Medication

Are you currently taking any medication?
Yes
No

Medical background

Give as much details as possible including dates

Are you currently under the care of a GP or specialist in the UK?
Yes
No
Do you have any of the following? (tick all that apply)

Urgency

How soon do you need this note/letter/certificate?
Same day
within a few days
Not urgent

Upload supporting documents

Upload any relevant documents 

Examples:

  • questionnaire (e.g. PADI / RSTC)

  • clinic letters

  • discharge summaries

  • test results

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