The Elizabeth Courtauld Surgery

01787 475944

MED3 Certificate Request

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.

  • DD slash MM slash YYYY
  • To receive confirmation of your request
  • So that we can contact you with any queries
  • DD slash MM slash YYYY
  • DD slash MM slash YYYY