Fit to Fly | Medical Cert

1

Name* This field is required.as it should appear on the certificate

2

Date of Birth* This field is required.

Date

3

Sex* This field is required.

Male

Female

Rather not say

4

Email* This field is required.where the certificate will be delivered

5

Phone* This field is required.Our clinical team may ring you on this number if they require any further information regarding your medical history

6

Why do you require a fit to fly certificate?* This field is required.

8

Please provide details, including dates where available* This field is required.

9

Do you have a history of any of the following lung conditions?* This field is required.

Asthma

COPD

Bronchiectasis or Cystic Fibrosis

Chest Infection / Pneumonia

Pneumothorax

None of the above

Other

10

Please provide details, including dates where available* This field is required.

11

Have you had surgery within the last 6 months?

YESNO

12

Please provide details of your surgery including dates* This field is required.You will be given an opportunity to upload your medical records later

13

Have you broken a bone or had a plaster cast applied within the last 48hours?* This field is required.

YESNO

14

Please provide details including dates* This field is required.You will be given an opportunity to upload your medical records later

15

Do you suffer from any Ear, Nose, or Throat conditions?* This field is required.Including middle-ear infections, effusions, active sinusitis, large nasal polyps, or recent ENT surgery

YESNO

16

Please provide details including dates* This field is required.You will be given an opportunity to upload your medical records later

17

Do you experience breathlessness or chest pain at rest?* This field is required.Including middle-ear infections, effusions, active sinusitis, large nasal polyps, or recent ENT surgery

YESNO

18

Please provide details* This field is required.You will be given an opportunity to upload your medical records later

19

Do you suffer from anaemia / low blood cell count?* This field is required.

YESNO

20

If you know your latest blood count (Haemoglobin) please enter it here, along with the approximate date it was taken:Your blood results are often available within your NHS app ('GP Health Records' > 'Test results')

21

Do you suffer from Sickle cell disease or trait?* This field is required.

YESNO

22

Have you suffered a sickling crisis within the last 30 days?* This field is required.

YESNO

23

Please provide details:

24

Do you have diabetes or high blood sugar?* This field is required.Including pre-diabetes

YESNO

25

How is your diabetes controlled?

26

Do you take any regular medication?* This field is required.

YESNO

27

Please list any regular medication you take:* This field is required.

28

Are you pregnant?* This field is required.

YESNO

29

Estimated Due Date* This field is required.

Date

30

Pregnancy Type* This field is required.

Single Pregnancy

Multiple Pregnancy

31

Have you experienced any complications or adverse events during your current pregnancy?* This field is required.

YESNO

32

Please specify the complications or adverse events experienced:* This field is required.

33

Do you have a history of any of the following pregnancy complications?* This field is required.Either in the current or previous pregnancies

Pre-eclampsia, High blood pressure in pregnancy

Placental abnormalities (eg. low-lying placenta)

History of early onset of labour (before 37 weeks)

Miscarriage(s) after 18 weeks gestation

Vaginal bleeding

None of the above

Other

34

Please provide further details* This field is required.

35

What was your latest antenatal clinic blood pressure reading?* This field is required.

Low (below 90/60mm Hg)

Normal (between 90/60 and 140/90)

High (over 140/90)

36

When was your most recent blood pressure reading taken?* This field is required.

Within 30 days

1-3 months ago

3-7 months ago

Over 7 months ago

37

My BMI was * at the start of my pregnancy.

38

When did you last see the Midwife/Obstetrician for review?

Date

39

Planned Travel Date (Outbound)* This field is required.

Date

40

Gestation at outbound (in weeks)* This field is required.We are only able to certify you as fit-to-fly if you are less than 36 weeks’ gestation (singleton pregnancy) or less than 32 weeks’ gestation (multiple pregnancy) on the date of your flight.

41

My flight is * hours long.

42

Planned Travel Date (Return)If your journey is one-way, leave blank

Date

43

Gestation at return (in weeks)We are only able to certify you as fit-to-fly if you are less than 36 weeks’ gestation (singleton pregnancy) or less than 32 weeks’ gestation (multiple pregnancy) on the date of your flight.

44

Please confirm that your midwife or obstetrician has not advise against flying* This field is required.

I have been medically advised that I may fly during this pregnancy

I have been medically advised NOT to fly during this pregnancy

45

Do you have any other medical condition, concern, or past medical history?* This field is required.

YESNO

46

Please provide further information* This field is required.

47

Airline / Holiday Provider

48

Does your airline/holiday provider require an additional specific form completed?You will be given the opportunity to upload this form and pay for it later. There is a £10 charge for additional forms.

YESNO

49

Please upload your required additional form:This will be completed in addition to our generic fit to fly certificate.

Drag and drop files here

Select files to upload

Max. file size: 10.6MB

50

Medical Evidence

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

A photo of your ID or Passport
A selfie (photo of yourself) for ID verification
Medical records: This can be your GP summary care record, screenshots of your GP Health Record from your NHS app, or hospital medical letters relevant to your condition(s).
If you are pregnant, we require a copy of your Antenatal / Maternity notes

Note: If you do not have your documents to hand, you can click the save icon below to save and return to this form later.

51

Please attach a photo of your travel ID / Passport as proof of identification.* This field is required.

Drag and drop files here

Select files to upload

Max. file size: 10.6MB

If you do not have this to hand, you can click on the save icon to save this form for later.

52

Take A Selfie* This field is required.Please take a clear photo of your face for ID verification

53

Please upload your GP Summary Care Record or documentation of your medical history* This field is required.Screenshots of all relevant pages of your health history from your NHS app are also acceptable. If you suffer from any specific medical conditions, please also upload any relevant medical letters.

Drag and drop files here

Select files to upload

If you do not have this to hand, you can click on the save icon to save this form for later.

54

A copy/pictures of your antenatal clinical notes* This field is required.All patients in the UK are provided with access to their maternity notes, which are often handwritten – or patients may have access to an app that contains the same information. Please attach a copy of all pages.

Drag and drop files here

Select files to upload

Max. file size: 10.6MB

If you do not have this to hand, you can click on the save icon to save this form for later.

55

Terms* This field is required.

I agree that upon submitting my medical consultation, I acknowledge the Terms and Privacy Policy and consent to the following: I am 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. I 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. I confirm I do not think I need to see a medical professional in person. Medical Cert is not my primary doctor or GP, and the doctor issuing my certificate may be unable to access my 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 my symptoms persist or I have not fully recovered, I agree to consult with my 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.

56

Fit-to-Fly

57

Payment* This field is required.

My Bag

1

Fit to Travel ConsultationIf we are unable to issue your certificate for any reason you will receive a full refund.
£67.00Edit
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Additional custom form(If you have uploaded a specific form to complete.)
£10.00Edit
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First Name

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