Request Application for Issuance Medical certificate

Below sample Request application Format for the issuance of Medical Certificate. You can use these sample issuance of a medical certificate from a doctor, institute, medical center, hospital etc. You can change these sample as per your requirement.

Request Application for issuance medical certificate


The Medical Specialist,

Doctor’s Hospital.

Dear Sir,

Subject: Request Application for issuance medical certificate

Dear Dr. Jennifer,

I am Ian, I was your patient of eyesight for a few weeks. You prescribed me medicine and told me to rest for 2 weeks at home whenever I start the medicine. I work at a multinational company called Winzip Insurance as an Administrator and I need a medical certificate so I can apply for a leave of 2 weeks. For leaves over a week, my company requires a medical certificate. Without the issuance of a medical certificate, my leave would not be approved. Please issue me a medical certificate stating that I need a rest of 2 weeks and during that time I won’t be able to come to the office. 

Kind Regards,


222, B- Baker Street, Lahore

Sample Medical Certificate Issuance Request

Doctor’s Hospital

Subject: Medical Certificate Issuance Request

Dear Dr. Emily,

I am Gabriel, 15 days ago I had an accident and I was put under your care. During that time, I had to miss University because for the initial 5 days I was admitted to the hospital and later on I was prescribed bed rest to let my injuries heal completely. Now that I’m fully fit, I’d like to resume going to my university. I was marked absent during the time I missed University and fined as well. In order to waive that fine, my university has asked me to get a medical certificate issued by the doctor I was getting treatment from. I request you to please issue me a medical certificate stating I met an accident and you prescribed me bed rest of 2 weeks so I can resume going to University and get the fine waived.

Kind Regards,



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