Medical Certificate

TO BE COMPLETED BY THE PERSON CLAIMING

To the GP of the person who was unwell

If you are the patient's specialist or consultant, please give this
form to the patient's GP for completion. Any fee due is the
responsibility of the claimant. Please complete ALL sections
below in BLOCK CAPITALS. If the information provided is unclear
or incomplete, this will lead to us contacting you for clarification
& will lead to a delay in assessing the claim. Please ensure that
the certificate is signed & stamped on page 4.

Claim Reference
Number
Patient Name
Patient DOB
Date of trip booking
Date of balance
payment

TO BE COMPLETED BY THE GP

About the patient

Has the patient suffered
from this condition
before? Please provide
the date of diagnosis.
Can they walk 200 yards
on the flat without
chest pain, tightness or
breathlessness?

What is the name of the

condition which caused
the claim?

What date did the patient

first consult a doctor
about this condition?

What is their height?

What is their weight?

If they were a smoker

but have given up, how
many years ago did they
do so?

Are they a smoker or an

ex-smoker?

Up to 1
year

1-10
years

10 years
+

Their medical condition when the trip was booked and when the balance was paid
When booked (dates above)
9

10

11

12

13

When balance paid (dates above)

Would they have been travelling

against medical advice?
Did they have a terminal diagnosis
or prognosis? (if yes provide
details)
Were they under review, having
tests or investigations, or awaiting
results for any existing diagnosed
or undiagnosed medical condition?
(if yes provide details)
Were they on a waiting list for any
inpatient treatment? (if yes
provide details)
Were they on a waiting list for any
outpatient treatment? (if yes
provide details)
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14

Had the patient been referred to a

consultant or specialist? (If yes
provide details)

Their medical condition in the last 24 months

Have they received any
15
treatment?

Inpatient Treatment

Outpatient Treatment

16 Dates of treatment

17 Details of treatment

Have they had any

serious, chronic or
18 recurring illness that
required advice,
medication or treatment?
19 Dates of treatment

20 Details of treatment

21

Please list the details of any medication taken regularly in the last 24 months, including any change of dosage.
Drug Name

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Medical Condition

Dosage

Start Date

Stop Date

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Their full medical history

22

Do they have any past or present history of any of the following medical conditions?
Condition Name

Y/N

Date of Diagnosis

Details (include comments on the stability of the condition)

Musculoskeletal disease
Malignancy
Thromboembolism /
thrombosis
Cardiac disease
Hypertension
Pulmonary disease
Hepatic disease
Renal disease
Endocrine disease
Gastroenterological
disease
Neurological disease /
epilepsy
Gynaecological / urological
Diabetes
Alcohol or drug abuse
Allergies
Psychiatric disease
Breast disease
Immunological disease

Any other conditions

If "No", please state which condition(s) the patient may not be aware of:

Is the named patient aware

of the above listed
conditions?

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Please provide us with any further information you feel may be relevant to the patient's medical condition,
including the results of any recent blood tests if applicable.

I am the GP of the patient named at the top of this form. I understand the above information to be a true reflection of
the patient's medical records
Surgery stamp
GP name

Surgery address

Surgery phone
number
Signed
Date

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