Medical certificate

 

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Personal Details
Your College or Academic Department
Details of the medical condition
• The original deadline and proposed new deadline • The title of the affected piece(s) of work • Your Reason why the duration of extension you are requesting is justified
Signature

Once your certificate has been completed, the practice will send it directly to your College and/or University (as applicable). The certificate is issued in confidence but may include information you have provided plus information from your health records that is relevant to your medical certification request. For further details on how we use and share your information, see our full privacy statement.

Please type your name here.
Confirmation

This form collects personal and medical information about you. We use this information to confirm you are registered with the practice and to allow the practice team to contact you if applicable. The information you send helps us to update your medical records held by the practice and our partners in the NHS. Please read our Privacy Policy to discover how we protect and manage your submitted data.

 
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