Hale Road Medical

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Reference Number

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Medical certificate type

Sick leave

Carers certificate

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Please select one of the following below:

For work

For UNI

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Pricing packages(Required)

$25 (medical certificate will be sent within 5 minutes of application)

$20 (medical certificate will be sent in 12 hours of application)

$15 (medical certificate will be sent in 48 hours of application)

First Name(Required)

Last Name(Required)

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Preferred option to received PDF(Required)

Phone sms

Email Address(Required)

Note: Please ensure you have the correct email address recorded otherwise you will not receive your Doctors Note.

Mobile Phone Number(Required)

Your Date Of Birth(Required)

DD slash MM slash YYYY

Unfit Date(Required)

DD slash MM slash YYYY

Address(Required)

Street Suburb Post Code Country

My Gender

Male

Female

Other

Caring for ( Person you are caring for )

Son

Daughter

Spouse

Father

Mother

Partner

Brother

Sister

Reason for a medical certificate(Required)

I understand that this application and medical certificate is for one day only.(Required)

I understand that this application and medical certificate is for one day only.

I undertand that this certificate will not be used as a "Fitness to go back to work".(Required)

I undertand that this certificate will not be used as a “Fitness to go back to work”.

I have applied for a semi-urgent Doctors Note and delivery will be via email in 12 hours and not prior.(Required)

I have applied for a semi-urgent Doctors Note and delivery will be via email in 12 hours and not prior.

I have applied for a non urgent Doctors Note and delivery will be via email in 48 hours (2 days) and not prior.(Required)

I have applied for a non urgent Doctors Note and delivery will be via email in 48 hours (2 days) and not prior.

Untitled(Required)

I confirm that above information I have provided is true, complete and accurate. I understand the Certificate will not be altered and there will not be a refund, if my information provided is inaccurate.

Untitled(Required)

please verify the above with your signature

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Payment Preference(Required)

Stripe

Paypal

Payment Fee

Click on the dropdown for PayPal payment options.