Apply for a Sports Medical Certificate - Merlin Health

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info@merlinhealth.co.uk

info@merlinhealth.co.uk

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Tests
- Diabetes
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- Thyroid
- Vitamin D
About
Contact

Apply for a Sports Medical Certificate - Medical Questionnaire

Please fill in the medical questionnaire below and one of our doctors will review the information submitted. Once approved, your medical certificate will be sent to your email address. If we are unable to provide you with a certificate, you will be issued with a full refund. If you need any support, please reach out to us at info@merlinhealth.co.uk - you can expect a same-day response.

Please enable JavaScript in your browser to complete this form.

Your Details

Full Name *

First

Last

Email Address *

Your certificate will be sent to this email address

Date of Birth *

Mobile Number *

The doctor may call you if further information is required

Sex *

City and Country of Birth *

This information is often asked by European events on their medical form

Currently Resident In: *

This information is often asked by European events on their medical form

Address *

Address Line 1

Address Line 2

City

State / Province / Region

Postal Code

Your Medical History

Height *

Weight *

What was your last blood pressure reading? *

When was this blood pressure reading taken? *

Do you smoke? *

Yes
No

How much do you smoke? *

How many units of alcohol do you take in a typical week? *

Have you ever had any of the following conditions?

High Blood Pressure? *

Yes
No

Cardiac Arrhythmia? *

Yes
No

Stroke? *

Yes
No

Heart Attack? *

Yes
No

Rheumatic Fever?

Yes
No

Asthma? *

Yes
No

Bronchitis? *

Yes
No

Diabetes? *

Yes
No

Epilepsy? *

Yes
No

Thyroid Disease? *

Yes
No

Bleeding Disorders? *

Yes
No

Heat Stroke? *

Yes
No

Water Intoxication? *

Yes
No

Have you had any other medical issues you would like us to know about? *

Yes
No

If yes, please give further details here: *

Have you been admitted to hospital for any reason within the past 3 years? *

Yes
No

If yes, please give further details here: *

Have you ever been refused a sports medical certificate or health insurance? *

Yes
No

If yes, please give further details here: *

Do you have any type of chronic disease? *

Yes
No

If yes, please give further details:

Have you consulted your GP for anything in the past 3 years? *

Yes
No

If yes, please give further details here:

Heart Health

Do you have any previous history of heart disease? *

Yes
No

If yes, please give further details here:

Is there a history of sudden cardiac death in close relatives (parents, siblings, children) under the age of 50 years? *

Yes
No

If yes, please give further details here:

Have you ever suffered from chest pain or tightness while exercising? *

Yes
No

If yes, please give further details here:

Have you ever suffered from excessive breathlessness or wheeze when exercising? *

Yes
No

If yes, please give further details here:

Have you ever suffered from dizziness at any time? *

Yes
No

If yes, please give further details here:

Have you ever collapsed, fainted or lost consciousness at any time? *

Yes
No

If yes, please give further details here:

Have you ever suffered from palpitations (skipped or excessively fast heart beat) while exercising? *

Yes
No

If yes, please give further details here:

Current Medications

Do you currently take any medication? *

Yes
No

Please list all your medications here: *

Have you ever taken performance enhancing drugs? *

Yes
No

If yes, please give further details here: *

Have you ever taken steroids to improve sporting performance? *

Yes
No

If yes, please give further details here: *

Training History

Have you trained or are you planning to train adequately to attempt this sporting event? *

Yes
No

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

How long can you push your heart rate to 70% of its maximum for? (in minutes) *

If you are unsure, please write 'unsure' here

Have you completed any athletic events in the past? *

Yes
No

Please give further details here about athletic events you have participated in previously: *

Your Athletic Event

Please list the sporting event(s) within the next 12 months that you need this certificate for: *

If you have a medical certificate template you would like the doctor to sign, please upload it here:

Click or drag files to this area to upload. You can upload up to 100 files.

If your athletic event has a particular form or certificate that needs signing and stamping, please upload this here. If your sporting event does not have a specific certificate template, we will provide you with our own generic version of a sports medical certificate with our doctors signature and stamp.

Identification Confirmation

Please upload a clear image or scanned copy of your ID document to verify your identity (e.g. driving license, passport etc): *

Click or drag files to this area to upload. You can upload up to 100 files.

Anything Else? (Optional)

Is there anything else you would like to add before submitting your application? (Optional)

Please leave blank if you have nothing else to add

Are there any other documents you would like to upload as part of your application? (Optional)

Click or drag files to this area to upload. You can upload up to 100 files.

Terms and Conditions

Upon submitting your application, you acknowledge our Terms and Privacy Policy and consent to the following:

(1) You have comprehended the questions in the questionnaire and answered them honestly.

(2) The requested letter is solely for the individual with the provided name and details.

(3) You are aware that Merlin Health is not a replacement for a doctor's visit, nor is Merlin Health your primary doctor or GP, and healthcare professionals at Merlin Health are unable to access your NHS or regular GP medical records.

(4) You are aware that Merlin Health is unable to process refunds once our doctor has reviewed your request and you've been sent a certificate signed by them.

(5) You are aware that if a third party does not accept or rejects a Merlin Health letter or certificate, for any reason, neither Merlin Health nor our Doctors are responsible for any costs incurred.

(6) The information provided by you is correct and complete at the date it was submitted.

(7) You are aware that any certificate issued by Merlin Health is void if it is later discovered that any information has been falsely disclosed or deliberately withheld.

(8) You are aware that at Merlin Health, we do not offer a diagnosis, consultation or treatment service. No liability is accepted for any adverse events affecting you or any other party at any point in time.

(9) You agree to absolve both Merlin Health and our doctors of any liability for any adverse events affecting you or any other party at any point in time.

(10) You are aware that this sports 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 within the limitations of an online assessment.

(11) You are aware that dynamic studies of cardiac function such as cardiac echocardiography 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.

(12) You are aware that our certificates are simply intended to satisfy the entry criteria for certain sporting events. They are not a guarantee against adverse events during exercise. They are not an insurance policy. They are not valid as medical indemnity.

Agreement to Terms and Conditions *

I have read and agree to the Terms and Conditions listed above

Checkout

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Sports Medical Certificate

Price: £59.00

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