Confirmation Required
If you proceed with an order, our doctor will call you on the below number to explain potential side effects and answer any questions you may have. Please ensure that your phone number is correct as the doctor cannot write a prescription without speaking with you first.
For our doctors to be able to issue you a medical certificate, we need some information from you.
DO YOU AGREE AND CONSENT TO THE FOLLOWING?- Please answer all questions carefully as requested, if there is any missing responses, unfortunately we will have to cancel your request.
- Please note, you are only allowed five medical certificates over a period of six months and we can only issue a maximum of two days at a time.
- If you require more than two days, please book a consult with our doctor.
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Which country do you live in? *
1
Why are you unable to attend work?
2
What is the relationship to the person you are caring for? (e.g. parent/caregiver or spouse)
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3
What is the first day you are unable to attend?
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How many days do you require?
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Please have the person you are caring for answer the following questions or you may answer on their behalf.
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Please fill this in
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What symptoms have you been experiencing?
7
How long have you been sick for?
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8
Is there any chest pain, shortness of breath, sever headache, fever higher than 39, stiff neck, loss of consciousness, severe abdominal pain, uncontrolled vomiting, visual disturbance, one sided body muscle weakness, loss of control over your bladder or bowels(incontinent)?
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Please explain as much as possible about your symptoms?
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10
Do you need any medications? Do you need to speak to a doctor?
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Will you see your doctor within the next day if your symptoms not improving?
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Do you acknowledge that the certificate will be given for up to two days only, you can order a maximum of 5 certificate in a 6 months period. If you require multiple days you need to speak to your regular GP?
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Would you agree to go to emergency department or call 000 if your medical condition gets worse?
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Will you acknowledge that our service is very limited and we as doctors rely on your statement and can not guarantee any misdiagnosis as we are not able to directly examine you?
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Do you understand everything that is written above or do you require assistance or language interpretation?
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How long have you been suffering from your condition?
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17
Are you taking any medications for any reasons?
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Please list which medications you take.
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19
Have you ever been treated for mental illness in the past?
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please explain what mental illness you have been treated for in the past?
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21
Have you had any prior mental illness diagnosis?
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Please provide details on your previous mental illness diagnosis
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23
Has your sleep been disturbed?
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Have you been feeling suicidal or self harm?
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Have you ever tried to self harm or attempt a suicide?
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Is there any family history of suicide in your family?
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Do you hear any voices or see things that are not real such as hallucinations?
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Do you use any recreational drugs?
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Will you agree to see your regular GP within next day if no improvement in your symptoms?
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Would you agree to call 000 or life line number on 13 11 14 if feeling suicidal or self harm?
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Would you acknowledge that your symptoms are mild and do not need urgent medical or psychiatric attention?
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Please enter your gender
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Discretion is at the heart of what we do but for legal reasons the name on your medical certificate must be your full legal name. Please provide your legal name as per your official government ID.*
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15
Please enter your date of birth. *
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Please use this format (DD/MM/YYYY)
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Based on your medical history and individual needs, our doctors have provided a personalised medical certificate. Please complete your mobile phone number to purchase your medical certificate for $29.95*
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Unfortunately based on your answer you would not be suitable for treatment.
If you made a mistake, you can go back and correct your answer.
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Unfortunately based on your answer you would not be suitable for treatment. If you would like to speak with the Burst doctor to discuss other treatment options, please book an appointment here .
If you made a mistake, you can go back and correct your answer.
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Please see your local GP.
If you made a mistake, you can go back and correct your answer.
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Please follow this link to book a $85 consultation with our doctor:
click here to book
If you made a mistake, you can go back and correct your answer.
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Thank you for filling out the form.
It has been sent to our doctor for review.