Single-day Medical Certificate for Work
Full Name
First Name
Last Name
Date of Birth
-
Day
-
Month
Year
Date
Email Address
Contact Number
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Aboriginal or Torres Strait Islander origin?
Please Select
Prefer not to say
No
Yes, Aboriginal
Yes, Torres Strait Islander
Sex assigned at birth
Please Select
Male
Female
Prefer not to say
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Medicare Card Number
Medicare Card Ref. Number
Concession Card Number (optional)
Concession Card Number (optional)
Emergency Contact Number
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Do you have any allergy?
Please Select
Yes
No
What medication you currently taking?
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1. What are you unable to attend? (Please note that we are unable to provide a medical certificate for WorkCover, Court or Centrelink purposes.)
Work
School
University
Other
2. What is the main reason for this leave?
Common cold or flu
Headache
Migraine
Back Pain
Period Pain
Anxiety, Stress or depression
Other
3. What is the first day you are unable to attend? (Please note we are unable to backdate medical certificates)
-
Day
-
Month
Year
Date
4. How many days will you be unable to attend for? (Please note that we are unable to offer medical certificates for more than 2 days without a consultation and we are unable to offer more than 5 medical certificates within a 6 month period.)
1 day
2 days
5. What symptoms have you been experiencing?
Flu-like symptoms
Gastro symptoms (vomiting and diarrhoea)
Headaches (including migraines)
Mental health symptoms
Injury – related symptoms
6. Would you describe these symptoms as mild and not requiring immediate medical care? (please see your doctor as soon as possible if your symptoms are not improving and go to your nearest emergency department or call 000 if your condition gets worse.
Yes
No
7. Are you experiencing any of the following symptoms?
Chest pain
Shortness of breath
Fever over 39 degrees
Extreme pain
Uncontrolled or excessive vomiting
Severe headache
Severe abdominal pain
Incontinence (loss control of your bladder or bowel)
Loss of consciousness
None of the above
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Online Medical Certificate
Single-day medical certificates
$
19.00
AUD
Credit Card
First Name
Last Name
Credit Card Number
Security Code
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