Travel & Holiday Cancellation Certificate

Your Personal Details

Please enter your name exactly as it should appear on the certificate.

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Full Name *

Date of Birth *

Sex *

Email Address *

Your certificate will be delivered here.

Phone Number *

Cancellation Details

Tell us about the trip and the reason for cancellation.

Airline / Holiday Provider (optional)

Planned Travel Date (Outbound) *

Planned Return Date (optional)

Main Reason for Cancellation *

Please describe your reason *

Pregnancy Details

Start Date of Symptoms * Enter the date your symptoms began, or when you first became unable to travel

Condition Status *

Ongoing

Partially Recovered

Recovered

Medical History

Please be as detailed as possible — more information means faster processing.

Describe your symptoms and timeline in detail *

A little more detail helps our doctors process your certificate faster.

Have you sought medical care from your GP or A&E for this issue? *

Yes, from my GP

Yes, I visited A&E

No, I have not consulted a doctor for this

What treatment was administered by your GP or A&E? *

Underlying health issues / past medical history I have no underlying health issues or past medical history to declare.

Regular medications (prescribed or over-the-counter) I take no prescribed or over-the-counter medications.

Are you pregnant or breastfeeding? *

Yes

Please provide pregnancy / breastfeeding details *

Medical Evidence

Please attach the following documents to support your claim.

⚠️

Documents not on this device? No problem — you can email them from your computer after completing this form. Send your files to [email protected] with your submission reference as the subject line. You'll receive your reference on the confirmation screen.

Medical Evidence (if available)

Photos of your condition, clinical letters, test results, prescriptions, screenshots from your NHS app, etc.

📎 Click to upload medical evidence

PDF, JPG, PNG, GIF or MP4 · Max 100MB · Multiple files allowed

A&E Discharge Summary (if applicable)

Upload your A&E discharge summary if you visited A&E.

📎 Click to upload discharge summary

PDF, JPG or PNG · Max 100MB

Travel ID or Passport

Name on ID must match the name on the certificate.

📎 Click to upload ID / Passport

PDF, JPG or PNG · Max 100MB

I will send the files via email to [email protected] instead of uploading now. (Please note, our doctors will start on your case once we have received your documents.)

Insurer Custom Form

Does your insurer require their own claim form to be completed by a doctor?

Do you need us to complete your insurer’s custom claim form? (+£15)

If your insurer has sent you a form that must be completed by a medical professional, we can fill it in as part of your consultation.

Upload Insurer Form

Upload the form your insurer sent you (PDF, JPG or PNG).

📎 Click to upload insurer form

PDF, JPG or PNG · Max 100MB

Review Your Details

Please check everything is correct before payment.

✏️ Not sure about something? Tap any section below to go back and edit.

I confirm that the information I have provided is accurate and complete to the best of my knowledge.

I consent to Medical Cert storing and processing the information I have submitted, including health information, in order to provide this service.

I understand that Medical Cert is unable to process refunds once a medical letter has been written and sent to me.

I request that the clinical review begins immediately and I acknowledge that I will lose my right to cancel once the service has been fully performed.

I agree to the Terms and Conditions (https://medicalcert.co.uk/terms-and-conditions/) and Privacy Policy (https://medicalcert.co.uk/privacy-policy/).

Disclaimer
Any medical certificate is void if information is later discovered to have been falsely disclosed or deliberately withheld. The certificate represents the doctor’s considered opinion based on the information available. It does not guarantee fitness or any specific outcome. Nothing in this disclaimer excludes or limits liability that cannot lawfully be excluded.

I have read and agree to the Terms and the Disclaimer above.

You must agree to the Terms and the Disclaimer to continue

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Travel Cancellation Certificate

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Travel Cancellation Certificate

Your Personal Details

Cancellation Details

Medical History

Medical Evidence

Insurer Custom Form

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