Medical Certificate, Referral & Document Request

This form is for regular patients requesting selected non-urgent doctor-prepared documents, including medical certificates, repeat specialist referrals, referrals to new specialists, brief medical letters and similar documents.

This form is not for requesting copies of medical records, test results, or general health information.

Important: Submitting this form does not guarantee that a document or referral will be issued. All requests are reviewed by the doctor or practice staff. A consultation may be required. This form is not for urgent medical problems. In an emergency, call 000.

Request type What type of doctor-prepared document are you requesting?

All requests are reviewed. A consultation may be required before a document or referral can be issued.

Patient details

Title

First name

Surname

Preferred name Mobile/contact phone Email address for reply/document

Medical certificate details

Requested certificate start date

Requested certificate end date

Date illness or injury started Information about your illness or injury

I confirm that I am genuinely unwell and recovering at home.

Select “Medical certificate” above to complete this section.

Referral details

The referral draft uses the generic referral template. The doctor may edit or add clinical details after review.

Allergies

Select a referral option above to complete this section.

Brief letter or other document

What is the document needed for?

Select “Brief medical letter” or “Other doctor-prepared document” above to complete this section.

Additional information and declarations Any other information

I confirm that I am a regular patient of Hampton & South Medical Centre.

I confirm that I have attended Hampton & South Medical Centre within the last 12 months.

I consent to the practice contacting me by email about this request and, if approved, sending the document to the email address I have supplied.

I understand this request will be reviewed and that a consultation may be required before any document or referral is issued.