Medical Certificates from medicalcert.co.uk

1
Name* This field is required.as it should appear on the certificate
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
Address* This field is required.
Street Address
Street Address Line 2
City
County
Post Code
United Kingdom
Please Select
Afghanistan
Albania
Algeria
American Samoa
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Angola
Anguilla
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Mali
Malta
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Montenegro
Montserrat
Morocco
Mozambique
Myanmar
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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
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Trinidad and Tobago
Tristan da Cunha
Tunisia
Turkey
Turkmenistan
Turks and Caicos Islands
Tuvalu
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Ukraine
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United States
Uruguay
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Vanuatu
Vatican City
Venezuela
Vietnam
British Virgin Islands
Isle of Man
US Virgin Islands
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Other
Country
7
Planned Travel Date (Return)
Date
Day
Month
Year
8
Start date of your symptoms* This field is required.
Date
Day
Month
Year
9
Condition status* This field is required.
Ongoing
Partially Recovered
Recovered
10
Please describe all your symptoms and timeline in detail. Please provide as much information and detail as possible.* 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
11
Can you confirm that over the last 48 hours, no new spots have appeared, and that all the chickenpox spots have now scabbed over?* This field is required.You will be asked to provide photos of your rash taken today. This can be attached at the end of this form or emailed to evidence@medicalcert.co.uk
Yes
No
12
Have you had any fever within the last 48 hours?* This field is required.
Yes
No
13
Have you been in contact with anyone with Monkeypox in the last month?* This field is required.Monkeypox can bear similarities to chickenpox, and there are rising cases worldwide.
Yes
No
14
Planned Travel Date (Outbound)* This field is required.
Date
Day
Month
Year
15
Chicken Pox Fit-to-Fly
16
Airline / Holiday Provider
17
Have you previously consulted your GP or another doctor for this rash?* This field is required.
Yes
No, I haven't consulted a doctor for this before
18
What treatment or advice did you receive?* This field is required.
19
Please list any underlying health issues or past medical history:If none, leave empty
20
Please list any regular medication you take, whether prescribed or over-the-counter:If none, leave empty
21
Medical Evidence

In order to issue your certificate, in the next pages you will be asked to provide:

A selfie for identification

A short video (30 sec - 1 min) or photos of your rash

A photo of your Travel ID or Passport

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.
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Take A SelfiePlease take a clear photo of your face for ID verification purposes
23
Please attach a video or photos of your rash taken todayPlease move the camera slowly and allow the camera to focus on the skin. Please include pictures of the chest, back, and torso.
Drag and drop files here
Select files to upload
Max. file size: 10.6MB
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Please attach a form of ID as proof of identification.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
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25
Terms* This field is required.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
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Chicken-pox recovery assessmentIf we are unable to issue your certificate for any reason you will receive a full refund.
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