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MediLeave Form

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Step 1 of 7 - Basic Information

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Certificate Reference Number

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Approver

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Your Information

(Enter the details of the Carer NOT the person you are caring for)

Name*

First Last

Sex/Gender*

Date Of Birth*

DD slash MM slash YYYY

Email*

Enter Email Confirm Email

Phone*

Address*

Street Address City State Postal Code Country

Digital Consultation

Please note this consultation is not intended to replace a doctor visit, medical treatment, opinion or diagnosis.

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Submit Date

DD slash MM slash YYYY

1. Leave Date

Please note we legally cannot provide a medical certificate for any days in the past (e.g. yesterday).

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2. Are you feeling unwell/unfit for work today due to a minor ailment/illness or injury?*

Yes

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2. Are you feeling unwell/unfit for School today due to a minor ailment/illness or injury?*

Yes

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2. Are you feeling unwell/unfit for University today due to a minor ailment/illness or injury?*

Yes

2. Who do you need to care for?*

Child

Parent

Partner

Housemate

Grand Parent

Sibling

Sorry you need to see a doctor in person.

2. You are suffering from ( please choose from the following symptoms).*

Cold and flu-like symptoms

Mild headache (same as before)

Migraine

Gastro (diarrhea/vomiting)

Mild back pain

Period pain (same as before)

Toothache

Hay fever

Allergies

Other mild symptoms (We may need to call you for a brief consultation)

Minor injury (We may need to call you for a brief consultation)

When did these symptoms first arise?*

Today

Yesterday

2 days ago

3 days ago

4 days ago

5 days ago

6 days ago

1 week ago

More than a week ago

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How long have you had cold & flu symptoms for?*

7 days or less

More than 7 days

Sorry we cannot issue you with a certificate. You require a more detailed consultation with a doctor. Please see a doctor in person as soon as possible.

Do you have any of the following conditions or symptoms associated with your cold& flu symptoms?*

Pregnant

Difficulty breathing/shortness of breath

Chest pain

Headache accompanied by neck stiffness

Rash which doesn’t fade when you press on it

Discomfort when looking at bright lights

Fever over 39°C

Coughing up blood/blood stained phlegm

Unable to swallow solids and fluids

Weak immune system (immunocompromised)

Feeling very unwell

None of the above

It sounds like you may have a serious health issue. An online certificate is NOT suitable in a medical emergency. Please seek immediate medical attention and/or call an ambulance by dialing 000

Sorry we cannot issue you with a certificate for an illness/injury that requires a consultation with a medical practitioner/doctor. Please see a doctor as soon as possible.

When did your headache start?

Less than 48 hours ago

More than 48 hours ago

Your symptoms require you to see a doctor in person. Please visit your GP/ a doctor as soon as possible.

Do you have any of these conditions or symptoms with your headache?*

Headache that feels different from any you've have before

Headache that doesn't feel like tightness or pressure around your head

Severe headache that comes on suddenly

Feeling very unwell

Head injury within the past 3 months

Nausea or vomiting or loss of balance

Confusion or drowsiness

Sensitivity to light

Seizure

Worsening headache symptoms over time

Frequent headaches, more than twice a week

Pain in the eye or blurred vision

Yes

Your answer indicates you may have a more serious condition and need to seek medical attention. Seek medical attention/ a doctor immediately

Have your headaches been previously confirmed as migraine by your doctor?*

Yes

Your answer indicates that you need to do a more detailed consultation and need to see a doctor/seek medical attention

Are your current migraine symptoms the same/similar as you’ve had before?*

Yes

Your answer indicates that you need to do a more detailed consultation and need to see a doctor/seek medical attention

Do you have a fever, flu like symptoms or confusion with your current headache?*

Yes

Your answer indicates that you need to do a more detailed consultation and need to see a doctor/seek medical attention

Have you had a head injury in the last 3 months?*

Yes

Your answer indicates that you need to do a more detailed consultation and need to see a doctor/seek medical attention

Do you have uncontrolled hypertension (high blood pressure)?*

Yes

Your answer indicates that you need to do a more detailed consultation and need to see a doctor/seek medical attention

Have you had your symptoms more than 7 days?*

Yes

Sorry we cannot issue you with a certificate as your condition requires a more detailed consultation with a doctor. It is important that you see a doctor as soon as possible.

Are you pregnant?*

Yes

We cannot issue you a certificate. Your condition may indicate a more serious condition, and it’s important that you see a doctor as soon as possible

Do you have any of these conditions or symptoms with your diarrhoea/vomiting?

Blood in your vomit or poo, or is your poo black and tarry

Severe abdominal/tummy ache

Fever or chills

Signs of dehydration (dizzy, unable to drink sips of fluid, passing little or no urine)

Diarrhoea alternating with constipation

Diarrhoea after recent travel overseas or tropical climate

Feeling very unwell

None of the above

We cannot issue you a certificate. Your condition may indicate a more serious condition, and it’s important that you see a doctor as soon as possible

Have you had back pain for more than 7 days?*

Yes

Sorry we cannot issue you with a certificate as your condition requires a more detailed consultation with a doctor. Please see a doctor as soon as possible

Do you have any of the following?*

Back pain that is spreading into one or both legs
Pins and needles or numbness around your anus or behind your genital area
Any weakness in your legs
Loss of bladder or bowel control
Pain when passing urine or passing urine more frequently
Any fever or “flu-like” symptoms
Losing or lost weight without trying to

Yes

Sorry we cannot issue you with a certificate as your answer indicates a more serious issue that requires you to see a doctor. Please see a doctor as soon as possible

Is there any chance you could be pregnant?*

Yes

Sorry we cannot issue you with a certificate as your answer indicates a more serious issue that requires you to see a doctor. Please see a doctor as soon as possible

Do you have a fever or flu-like symptoms?*

Yes

Sorry we cannot issue you with a certificate as your answer indicates a more serious issue that requires you to see a doctor. Please see a doctor as soon as possible

Do you have any foul smelling/abnormal vaginal discharge?*

Yes

Sorry we cannot issue you with a certificate as your answer indicates a more serious issue that requires you to see a doctor. Please see a doctor as soon as possible

Is the current period pain you are having much more severe than your previous period pain episodes?*

Yes

Sorry we cannot issue you with a certificate as your answer indicates a more serious issue that requires you to see a doctor. Please see a doctor as soon as possible

Do you have a scheduled dental appointment and are currently waiting for it?*

Yes

We cannot issue you a certificate unless you have made an appointment to see a dentist or doctor

How long have you had dental pain/toothache?*

48 hours or less

More than 48 hours

You are not eligible to get a certificate online for a dental pain that lasted more than 2 day. Please see a GP or dentist to obtain your certificate.

Does your tooth pain /dental pain spread to other areas, such as the eyes, ears or jaw?*

Yes

We cannot issue you a certificate unless you have made an appointment to see a dentist or doctor

Do you also have a fever (over 38°C)?*

Yes

Your symptoms may indicate a more serious condition, and it’s important that you see a doctor as soon as possible.

How long have you had hay fever symptoms?*

Less than 2 days

More than 2 days

Your symptoms require you to see a doctor in person. Please visit your GP/ a doctor as soon as possible.

How long have you had allergic symptoms for?*

Less than 2 days

More than 2 days

Your symptoms require you to see a doctor in person. Please visit your GP/ a doctor as soon as possible.

Describe your allergy symptoms.*

Please describe your symptoms.*

Please note we are unable to issue certificates for mental health related requests.

Please describe your injury.*

3. Are your symptoms mild and can you manage them at home by yourself?*

Yes

We are unable to issue you a certificate. Seek medical assistance / your doctor for your symptoms

3. Does the person you are caring for have ANY of the following symptoms?*

Difficulty breathing

Shortness of breath

Fever over 39°C

Extreme pain

Chest pain

Blood in your vomit or poo, or is your poo black and tarry

A sudden onset severe headache worse than any previous headache

Headache associated with decreased alertness and is different from previously diagnosed migraine/tension headache

Severe abdominal pain

Neck stiffness

Sudden changes in your vision, dizziness or confusion

Excessive vomiting and are unable to keep any fluids down

Slurred speech, drooping face, new weakness, or numbness in any limb

Yes

We are unable to issue you a certificate. Call 000 and seek medical assistance immediately.

4. If you are looking after your child, do they have the following symptoms?*

Signs of dehydration (lack of urine, dry nappies, absence of tears, dry mouth and mucosa, lethargy and difficulty waking them up).

Rashes associated with drowsiness and neck stiffness.

Inability to feed them or not tolerating oral intake.

Yes

Not Applicable (I'm not caring for a child)

We are unable to issue you a certificate. Call 000 and seek medical assistance immediately.

4. Will your symptoms affect your work duties?*

Yes

4. Will your symptoms affect your school duties?*

Yes

4. Will your symptoms affect your university duties?*

Yes

We are unable to issue you a certificate.

5. Do your symptoms require urgent medical attention?*

Yes

We are unable to issue you a certificate as this is a medical emergency. Call 000 or seek medical attention immediately.

5. How would you describe the condition of the person you are caring for?*

Sick or Injured

They have an unexpected NON-MEDICAL emergency

Has the sick or injured person seen or made as appointment with a healthcare professional?*

Yes, they have already seen a healthcare professional for this condition

Yes, they have an appointment booked

None of the above

We are unable to issue you a carer’s leave certificate . A carer’s certificate can only be issued if the person has seen or has an appointment with a healthcare professional. Please arrange an appointment.

Will you take them to a doctor or seek medical attention for them if they don’t get better within the next 24 hours?*

Yes

We cannot proceed to issue you a certificate. If your household/immediate family member’s symptoms do not improve or get worse then you need to seek medical treatment/attention for them.

6. Will you see a doctor or seek medical attention if your symptoms do not improve or get worse within 24 hours?*

Yes

We are unable to issue you a certificate. If your symptoms persist or get worse than medical attention must be sought.

7. Do you have ANY of the following symptoms?*

Difficulty breathing

Shortness of breath

Fever over 39°C

Extreme pain

Chest pain

Blood in your vomit or poo, or is your poo black and tarry

A sudden onset severe headache worse than any previous headache

Headache associated with decreased alertness and is different from previously diagnosed migraine/tension headache

Severe abdominal pain

Neck stiffness

Sudden changes in your vision, dizziness or confusion

Excessive vomiting and are unable to keep any fluids down

Slurred speech, drooping face, new weakness, or numbness in any limb

Rash which doesn't fade when you press on it

Any condition or medication that can affect your immune system

Yes

We are unable to issue you a certificate. Call 000 and seek medical assistance immediately.

Supporting Documents (You may optionally add any supporting photos or documents for the doctors to review such as Scans, COVID RAT Test etc.)

Accepted file types: jpg, gif, png, pdf, Max. file size: 64 MB.

6. Have you understood and answered all of these questions truthfully and accurately?*

Yes

Unfortunately, we cannot proceed to issue you a certificate.

8. Have you understood and answered all of these questions truthfully and accurately?*

Yes

Unfortunately, we cannot proceed to issue you a certificate.

Review Your Details

First Name:

Last Name:

Gender:

Date of Birth:

Email:

Phone Number:

Street Name:

Suburb:

State:

Postcode:

Confirmation and Consent

By clicking on the 'agree & continue' button below, you accept the terms & conditions which include information related, but not limited to, the following :

MediLeave can contact me for follow-up via call, text, or email.

All certificates are issued subject to the clinical opinion of the healthcare professional.

Certificates submitted between 11pm - 6am will be issued after 7 am next morning.

You can access the full Terms & Conditions here and our Privacy Policy here.

By clicking on the 'agree & continue' button below, you accept the terms & conditions which include information related, but not limited to, the following :

I understand Certificates cannot be back-dated.

For pregnancy-related issues, the person you are caring for will consult her GP or midwife asap.

I'll accept calls from a MediLeave clinician anytime.

MediLeave can contact me for follow-up via call, text, or email.

All certificates are issued subject to the clinical opinion of the healthcare professional.

Certificates submitted between 11pm - 6am will be issued after 7 am next morning.

The person I'm caring for and myself are both currently in Australia.

I agree to subscribe to MediLeave emails for news and offers. I can opt-out at anytime.

You can access the full Terms & Conditions here and our Privacy Policy here.

Confirmation and Consent*

By checking this box, you confirm that you have read and agree to the information in the section above and accept our Terms & Conditions and Privacy Policy. You will be added to our subscriber list, you can unsubscribe at any time.*