Medical Cert

1
Name* This field is required.as it should appear on the letter
First Name
Last Name
2
Date of Birth* This field is required.
Date
Day
Month
Year
3
Sex* This field is required.
Female
Male
Prefer not to say
4
Email* This field is required.where the certificate will be delivered
5
Phone* This field is required.
6
What is the main reason for this referral?* This field is required.
Please Select
Please Select
Diagnosis
Medication
Investigation
Second Opinion
Ongoing Care
Other
7
Please describe your issue, symptoms, or concern in detail. Include relevant dates, previous operations, treatments or medications.* This field is required.More detail will help our doctors issue your letter quickly. Insufficient detail may delay your letter, as our doctors may have to contact you for further clarification before issuing a letter.
20 words minimum.
0/0
8
What has already been tried to resolve the problem?* This field is required.e.g. any medication, treatment or therapies
9
Start date of your symptoms, problem, or concern* This field is required.
Date
Day
Month
Year
10
Do you take any medication? Either prescribed or purchased over-the-counter
YESNO
11
Please list any regular medication you take, whether prescribed or over-the-counter:If none, leave empty
12
Do you have any existing health issues or past medical history?
YESNO
13
Please list any underlying health issues or past medical history:
14
Full name of the specialist you'd like to be referred to
e.g. Dr John Doe
15
Specialist's Field of PracticePlease tell us which speciality you would like to be referred to, or you can ask us to decide for you based on your symptoms or problem.
16
Specialist's Clinic Address
Street Address
Street Address Line 2
City
State / Province
Postal Code
Please Select
Please Select
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
The Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bosnia and Herzegovina
Botswana
Brazil
Brunei
Bulgaria
Burkina Faso
Burundi
Cambodia
Cameroon
Canada
Cape Verde
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos (Keeling) Islands
Colombia
Comoros
Congo
Cook Islands
Costa Rica
Cote d'Ivoire
Croatia
Cuba
Curaçao
Cyprus
Czech Republic
Democratic Republic of the Congo
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Ethiopia
Falkland Islands
Faroe Islands
Fiji
Finland
France
French Polynesia
Gabon
The Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
North Korea
South Korea
Kosovo
Kuwait
Kyrgyzstan
Laos
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macau
Macedonia
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Nagorno-Karabakh
Namibia
Nauru
Nepal
Netherlands
Netherlands Antilles
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
Turkish Republic of Northern Cyprus
Northern Mariana
Norway
Oman
Pakistan
Palau
Palestine
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn Islands
Poland
Portugal
Puerto Rico
Qatar
Republic of the Congo
Romania
Russia
Rwanda
Saint Barthelemy
Saint Helena
Saint Kitts and Nevis
Saint Lucia
Saint Martin
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Slovakia
Slovenia
Solomon Islands
Somalia
Somaliland
South Africa
South Ossetia
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Svalbard
eSwatini
Sweden
Switzerland
Syria
Taiwan
Tajikistan
Tanzania
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Transnistria Pridnestrovie
Trinidad and Tobago
Tristan da Cunha
Tunisia
Turkey
Turkmenistan
Turks and Caicos Islands
Tuvalu
Uganda
Ukraine
United Arab Emirates
United Kingdom
United States
Uruguay
Uzbekistan
Vanuatu
Vatican City
Venezuela
Vietnam
British Virgin Islands
Isle of Man
US Virgin Islands
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Other
Country
17
Are you registered with a UK NHS GP?* This field is required.
Yes
No
18
NHS Number* This field is required.
19
Your NHS Surgery* This field is required.
Please provide the name of your NHS GP
20
NHS GP Surgery AddressPlease provide the address of your NHS GP practice
Street Address
Street Address Line 2
City
County
Post Code
Please Select
Please Select
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
The Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bosnia and Herzegovina
Botswana
Brazil
Brunei
Bulgaria
Burkina Faso
Burundi
Cambodia
Cameroon
Canada
Cape Verde
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos (Keeling) Islands
Colombia
Comoros
Congo
Cook Islands
Costa Rica
Cote d'Ivoire
Croatia
Cuba
Curaçao
Cyprus
Czech Republic
Democratic Republic of the Congo
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Ethiopia
Falkland Islands
Faroe Islands
Fiji
Finland
France
French Polynesia
Gabon
The Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
North Korea
South Korea
Kosovo
Kuwait
Kyrgyzstan
Laos
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macau
Macedonia
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Nagorno-Karabakh
Namibia
Nauru
Nepal
Netherlands
Netherlands Antilles
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
Turkish Republic of Northern Cyprus
Northern Mariana
Norway
Oman
Pakistan
Palau
Palestine
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn Islands
Poland
Portugal
Puerto Rico
Qatar
Republic of the Congo
Romania
Russia
Rwanda
Saint Barthelemy
Saint Helena
Saint Kitts and Nevis
Saint Lucia
Saint Martin
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Slovakia
Slovenia
Solomon Islands
Somalia
Somaliland
South Africa
South Ossetia
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Svalbard
eSwatini
Sweden
Switzerland
Syria
Taiwan
Tajikistan
Tanzania
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Transnistria Pridnestrovie
Trinidad and Tobago
Tristan da Cunha
Tunisia
Turkey
Turkmenistan
Turks and Caicos Islands
Tuvalu
Uganda
Ukraine
United Arab Emirates
United Kingdom
United States
Uruguay
Uzbekistan
Vanuatu
Vatican City
Venezuela
Vietnam
British Virgin Islands
Isle of Man
US Virgin Islands
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Other
Country
21
Medical Evidence

In order to issue your referral letter, in the next pages you will be asked to:

Upload a video of you describing your symptoms, problem, or concern.

Upload a photo of your ID or Passport

Take a selfie (photo of yourself) for ID verification

Note: If you are not ready to provide these now, you can click the save icon below to save and return to this form later.
22
Please upload a video of you describing your reason for referral* This field is required.
Drag and drop files here
Select files to upload
Max. file size: 10.6MB
Our doctors can only begin working on the certificate if this is received,
Cancelof
23
Please attach a photo of your ID as proof of identification.* This field is required.Accepted forms of ID include: photo of your driver's license, passport, work badge, residence permit, or military ID card.
Drag and drop files here
Select files to upload
Max. file size: 10.6MB
Our doctors can only begin working on the certificate if this is received,
Cancelof
24
Take a Selfie * This field is required.Please take a clear photo of yourself for identity verification purposes.
25
If you have any other supporting documentation you can upload this hereThis can be photos of your condition, copies of medical communication, prescriptions, test results, screenshots from your NHS app, etc.
Drag and drop files here
Select files to upload
Max. file size: 10.6MB
Cancelof
26
Information & Terms* This field is required.This referral service is designed for non-emergency situations and is not intended for conditions requiring immediate attention from a doctor. If you are experiencing any of the following, we cannot facilitate a referral for you. Instead, it is crucial to contact 111 or visit your local Accident and Emergency (A+E) department. These conditions include but are not limited to chest pain, shortness of breath or difficulty breathing, infections with symptoms like fevers or new rashes, new severe headaches, collapse, loss of consciousness, seizures or fits, slurred speech, loss of power to any muscles or facial droop, heavy bleeding, severe mental health problems including suicidal thoughts, sudden loss of vision, or eye pain. In such cases, immediate medical attention is essential. Upon submitting your medical consultation, you acknowledge our Terms and Privacy Policy and consent to the following: - You are NOT seriously unwell with any of the following symptoms: chest pain, shortness of breath, unrelenting severe headache, worsening severe abdominal pain, loss of vision, thoughts of suicide, confusion, ongoing bleeding, unable to swallow fluids or saliva, loss of limb sensation or control, facial numbness or weakness, slurred speech. - You understand the questions in the questionnaire and answered them honestly. - The requested letter is solely for the individual with the provided name and details. - Medical Cert is not a replacement for a doctor's visit. You confirm you do not think you need to see a medical professional. - Medical Cert is not your primary doctor or GP, and the doctor issuing your certificate may be unable to access your NHS or regular GP medical records. - Medical Cert facilitates access to private medical letters and does not issue Med3 notes, which are obtainable through your NHS GP for UK government benefits. - Medical Cert is unable to process refunds once a medical letter has been written and sent to you. - If your symptoms persist or you have not fully recovered, you agree to consult with your regular doctor or GP for further medical advice. - I consent to having this website store my submitted information so they can respond to my inquiry.
I agree
27
Referral Letter
28
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