Carer Medical Certificate

Thank you for completing this assessment for our Pocket Lab doctors to review. Medical certificates are issued at the doctor's discretion and they may call you to gather further information.

Carer Details

First name

Last name

Middle name

Code

Phone

Person Being Cared For

First name

Middle name

Last name

Date of Birth

Gender *

Male

Female

Other

Address

They are an international visitor or student

What is your relationship to this person? For example mother, father or partner

I declare that the person I am caring for DOES NOT have any of the following symptoms which require immediate medical attention: chest pain, difficulty breathing, severe pain, severe headache, severe abdomen pain, uncontrolled bleeding, uncontrolled vomiting, dizziness, unable to swallow foods or saliva, weakness or numbness of the face or limbs, speech difficulty, eye pain or new changes in vision.

How long have they had symptoms?

What symptoms have they had? Please provide as much detail as you can such as severity and frequency and list any treatments you have tried and their effectiveness.

What is the medical certificate for? For example work or study

How many days are you requesting for the medical certifcate? *

1 day

2 days

What is the START day you are requesting for the certificate? We are able to issue a medical certificate commencing no earlier than one day before this consultation. *

Yesterday

Today

Tomorrow

Provide any additional information for the doctor here

I declare that, in my judgement, the person under my care does not require immediate medical attention. However, I will promptly seek medical assistance if any cause for concern arises.

I understand that a medical certificate is a legal document and I declare that the information supplied is true and accurate.

I consent to a doctor calling me should further information be required to complete my request.

I agree to the Terms and Conditions and Privacy Policyhere

Thanks for submitting!