Health Screening Form

For the purposes of obtaining a medical test and certificate(s) to participate in competitive and non-competitive sporting events. Please provide full and detailed information and answer all questions. Please note that incomplete, incorrect, submissions will be returned for re-submission.

Contact Details

First Name

Surname

Address

City

Country

Region/State

Post/Zip Code

Telephone

Mobile

E-mail

Confirm E-mail

Select Password

Confirm Password

Date of Birth

City of Birth

Country of Birth

Save as Billing Address

Your Training

Have you been training and plan to train in an adequate fashion to attempt a sporting event?

Yes

How far are you cycling, running or swimming each week?

Cycling

Running

Swimming

How long do you push your heart rate to 70% of its maximum for?

minutes

Don't know

Have you completed any entrance events before?

Yes

Have you ever fainted?

Yes

How much do you smoke?

cigarettes per day

How much do you drink?

units per week

Are there any other medical issues that we need to be aware of?

Yes

Performance Enhancing Drugs

Have you ever taken performance enhancing drugs?

Yes

Have you ever taken steroids to improve sporting performance?

Yes

Medical Insurance

Have you ever been refused medical insurance?

Yes

Your Events

Please list the events you are entering over the next 12 months. You will be provided with our generic medical certificate if you have not requested a specific format. If any of your events require a specific certificate template or form, please indicate in this section and upload the required template. We will issue a signed, stamped and dated medical certificate valid for 12 months from approval.

Terms and Conditions

I understand that the personal information being submitted is securely protected under GDPR 2018. I also understand that this will only be used to assist in my entrance event. I also state that all the data provided is present, correct and complete at the date it was submitted.

Disclaimer

Any medical certificate is void if it is later discovered that any information has been falsely disclosed or deliberately withheld. Please be advised that the medical certificate does not guarantee fitness for an event, but represents the considered opinion of the Doctor with all the information available at the time.

It should be understood that dynamic studies of cardiac function such as cardiac echo or cardiopulmonary exercise testing provide a much more accurate assessment of cardiovascular fitness, however this type of specialist testing is not required for the medical certification process unless clinically indicated. Read full disclaimer.

I have read and accept the terms and conditions.

I have read and accept the disclaimer.

I agree to being contacted in future.

Form Complete

Please click the 'Add to Basket' button below to confirm your order and proceed to payment.

Form Ref.	Details	Price
	Sports Medical Certificate	£62.50 (exc. VAT)

Certificate

Your health screening form will not be reviewed by a GP/Doctor, and therefore your certificate won't be issued, until you have completed payment.

Health Screening Form

Contact Details

Your GP

Medical Condition

Medical History

Heart Disease

Your Current Medication

Hospital

Your Training

Performance Enhancing Drugs

Medical Insurance

Your Events

Terms and Conditions

Disclaimer

Form Complete

Certificate

Frequently Asked Questions

"What if my event requires full diagnostic testing?"

"How long will it take?"

"What if the Doctor needs to ask me more questions?"

"Do I have to pay if the Doctor can't issue a certificate?"

"What if I lose my password?"

"What if I want to talk to a Doctor?"

Complete the online Health Screening Form

Pay the £75.00** fee securely via PayPal*

Doctors will assess if you are fit for your chosen event/s

Doctors upload certificate for download from your account