FastDoc Medical Letter Form

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Timer

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Get Page URL

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View

Customer

Doctor

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Adjusted Wording for Letter (Doctor input only)* This field is required.

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Time

Hour

Minutes

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Submission Date

Date

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Submission ID

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Assigned to

Bilal

Josh

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Medical letter typePlease select the medical letter that you need

Sick Note for Work

Travel and Holiday Cancellation

Fit to Fly: Pregnancy

Student Sick Note

Gym Cancellation

Workplace Adjustments

Travel with Medication

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Formal Letter Title

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Name* This field is required.Full name of the person who requires the letter

First Name

Last Name

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Email* This field is required.

example@example.com

Confirm Email

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Date Of Birth* This field is required.

Date

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Do you have any relevant pre-existing health conditions your Partner Practitioner should be aware of?* This field is required.

YESNO

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Pre-existing health conditionsPlease only provide pre-existing health conditions that are relevant to this requested medical letter

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Are you taking any medications regularly?* This field is required.

YESNO

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Regular medications

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Main symptoms (select all that apply)* This field is required.

Cold or flu-like

Stomach bug (nausea, vomiting or diarrhoea)

Fever or feeling unwell

Headache or migraine

Back, neck or muscle pain

Period pain

Stress, anxiety, depression or low mood

Other

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Date symptoms started* This field is required.

Date

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Brief description of your condition and timeline (optional)

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Would you like specific symptoms included in the letter?

Yes - include details

No - keep it general

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Current Condition Status

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Current Condition State

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When do you want the letter to start?* This field is required.Please choose the date that you want your letter to be valid from

Date

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Backdated (Days)

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When do you want the letter to be valid until? (Inclusive)* This field is required.Please choose the date the you want your letter to be valid to

Date

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Letter Duration (Days)

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Name of your Workplace* This field is required.

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Work Activities* This field is required.

Desk-based / computer work

Heavy physical work (lifting, carrying, manual labour)

Prolonged standing or walking

Driving or operating machinery

Safety-critical duties (e.g. healthcare, working with children, hazardous environments)

High stress or concentration-intensive work

Other

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Describe the work adjustments and timeline* This field is required.Please describe the specific adjustments and timeline requested

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Name of school / college / university* This field is required.

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What is this sick note for?* This field is required.

General Absence from classes

Missed exam

Missed coursework deadline

Placement / practical requirement

Other

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Name of gym / fitness provider* This field is required.

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What would you like to request?* This field is required.

Freeze Membership

Cancel Membership

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End date of your membership freeze

Date

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Start date of symptoms or condition* This field is required.

Date

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Please describe your health condition and how it affects your ability to exercise or attend the gym* This field is required.

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Are you currently receiving treatment or taking medication for this condition?* This field is required.

YESNO

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Please provide brief details of treatment or medication

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Please provide further details about why you're unable to travelProvide more details for unforeseen reason and timeline

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Was this present at the time you booked your travel?* This field is required.

YESNO

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Are you having a single or multiple pregnancy?* This field is required.

Single

Multiple (twins, triplets etc)

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Estimated Due Date* This field is required.

Date

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Have you experienced any complications?* This field is required.

YESNO

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Please provide details of any complications (e.g. high blood pressure, bleeding, gestational diabetes, preterm labour, blood clots).

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Have you been diagnosed with high blood pressure?* This field is required.

YESNO

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Has your midwife, obstetrics team or any other healthcare professional advised you against flying?* This field is required.

YESNO

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Which airline are you travelling with?* This field is required.

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Date of Outbound Travel* This field is required.

Date

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Date of Return Travel (Optional)

Date

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Outbound Travel Gestation (Weeks)

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RETURN Travel Gestation (Weeks)

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Flight duration* This field is required.

Short Haul: 1-3 hours

Medium Haul: 3-6 hours

Long Haul 6+ hours

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Fit to Fly Acknowledgment* This field is required.

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Please briefly describe your health condition(s) for which you've been prescribed medication.* This field is required.

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How many medication are you traveling with?* This field is required.(Please note that your Partner Doctor can confirm you're traveling with up to 3 different medication per letter issued)

1

2

3

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Prescriber Full Name* This field is required.

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Prescriber Professional Registration* This field is required.

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Upload Prescription(s)* This field is required.Please upload a copy of your prescription(s) or repeat medication list. This must show the prescribing doctor’s name and signature. Where available, additional details such as their professional registration number are also helpful.

Drag and drop files here

Select files to upload

Max. file size: 10.6MB

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Risk

Low

High

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Choose Priority Option* This field is required.

£24.99 | Same Day Delivery | POPULAR

£49.99 | Priority Delivery | FASTEST

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Terms of Service* This field is required.

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Service Price

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Payment Total* This field is required.

Description

GBP

+ OR enter a custom value

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Payment Methods

Debit Or Credit Card

Choose from one of the PayPal options to make your payment.