MED3 Certificate Request – The Elizabeth Courtauld Surgery

Please allow 2 working days before receiving the MED3 Certificate. Remember the details you submit will be sent to us by unencrypted email via the Internet. This means that complete confidentiality is not possible because we cannot guarantee the security of the Internet. If you are not comfortable with this arrangement you may prefer to call the admin team with your request.

Please ensure you complete ALL of the sections marked with an * otherwise the form cannot be sent.

Name*
First Last
Date of birth*
DD slash MM slash YYYY
Email address*
Enter Email Confirm Email
To receive confirmation of your request
Daytime telephone number*
So that we can contact you with any queries
Start date (cannot be in the past)*
DD slash MM slash YYYY
End date*
DD slash MM slash YYYY
Medical conditions this request relates to*
Consent*
I agree to the privacy policy.
Please note that no medical information or questions will be responded to. The data you supply on this form will be stored on our website, which is hosted by a third party, until it has been processed by the practice. The data will be used lawfully, in accordance with the Data Protection Act 2018, which gives you the right to know what information is held about you, and sets out rules to make sure that this information is handled properly. The practice privacy policy can be viewed on this website.