Health Beacon
Medical Certificate Form
1
Diagnosis Information
2
Your Details
Certificate Type
*
Single Day Certificate
Multi-Day Certificate
Leave Type
*
It's for me
It's for someone else (Carer leave)
This leave is from
*
Work
Studies
Flight or Travel
What are your symptoms?
*
Common cold
Flu
Diarrhea
COVID-19
Depression
Food poisoning
Migraine
Headache
Allergies
Back pain
Period pain
Toothache
Anxiety/Stress
Other
Please provide the timing and a description of your symptoms:
Start Date
*
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