Medical Certificates

Purpose of Certificate

Note: This form is for requesting a non-emergency medical certificate. All requests are reviewed by a registered healthcare professional. Submitting this form does not guarantee a certificate will be issued.

Why are you requesting a medical certificate? *

Illness or injury Carer responsibilities Other (please specify below)

If 'Other', please describe:

Is this certificate for work, study, or another purpose? *

Work Study Other

Health Background

Tell us about your symptoms and current condition. This information is confidential and helps the doctor assess whether a certificate is appropriate.

What symptoms are you experiencing? *

When did your symptoms start? *

Have you seen a doctor or received treatment for this issue?

Yes No

If yes, please provide details (doctor name or clinic):

Certificate Details

Important: Certificates will only cover dates deemed medically reasonable by our practitioners. Backdating is only possible with adequate clinical justification.

What dates are you requesting the certificate to cover? *

Do you require any special notes (e.g. fitness for work, light duties)?

Have you previously requested a certificate for this condition?

Yes No

Please tell us briefly what brings you to see the doctor today. *

Consent & Signature

Declaration: I confirm that the information I have provided is true and complete. I understand that a medical certificate will only be issued if clinically appropriate, and that the reviewing doctor may contact me for further information if needed.

Consent *

I confirm that all information provided is accurate and I understand that a certificate may not be issued if criteria are not met.

Signature *

Confirm Your Details

We’ll use your email to match your booking. Please enter your Medicare number to confirm.

Email *

Medicare Number *

Medicare Reference *

Medical Certificates​

Request a Medical Certificate