Request Certification

Complete this form to begin your FMLA, short-term disability, or ADA accommodation evaluation. Most patients are seen same-day.

About You

Employment

Condition

Leave & Upload

Review

About You

Basic information for your medical record.

First Name *

Last Name *

Email *

Phone

Date of Birth

Employment Details

We need your employer information for the certification paperwork.

Employer Name *

Employer Phone

FMLA Coordinator / HR Contact

If known — helps us send forms directly

Your Job Title

Employment Start Date

FMLA requires 12+ months with employer and 1,250+ hours worked

Your Condition

This helps us prepare the right documentation for your visit.

Condition Category *

Mental Health

Anxiety, depression, PTSD, bipolar, etc.

Chronic Condition

Migraines, fibromyalgia, IBS, autoimmune, etc.

Surgery / Recovery

Post-surgical recovery, planned procedure

Pregnancy / Maternity

Pregnancy complications, maternity leave

Physical Injury

Back pain, musculoskeletal, sports injury

Other

Cancer treatment, family care, other conditions

Brief Description

When did symptoms begin?

Are you currently seeing a provider?

Leave Request & Documents

Select the type of certification you need and upload any employer-provided forms.

What certification do you need? *

FMLA — Intermittent

Take leave as needed (e.g., 2-3 days/month for flare-ups)

FMLA — Continuous

Extended block of leave (e.g., 6-12 weeks for surgery)

Short-Term Disability

Documentation for STD insurance claim

ADA Accommodation

Workplace accommodation letter (remote work, schedule change, etc.)

Leave Schedule *

Intermittent

As-needed basis

Continuous

Consecutive block

Reduced Schedule

Fewer hours/days

Estimated Leave Start

Estimated Leave End

Employer FMLA Form (if provided)

📄

Click to upload or drag and drop

PDF, JPG, PNG, DOC — Max 10MB

If your employer gave you a specific form (WH-380-E, WH-380-F, or company form), upload it here.

Review & Submit

Please verify your information before submitting.

Patient Information

Name

Phone

Date of Birth

Employment

Employer

Job Title

FMLA Coordinator

Medical Condition

Leave Request

Certification Type

Leave Schedule

Leave Dates

Uploaded Form

I confirm this information is accurate and I consent to a telehealth evaluation for medical certification purposes. I understand this is a real medical consultation with a board-certified physician.

Privacy: Your information is transmitted securely and used solely for medical certification purposes. We comply with HIPAA and applicable telehealth regulations.

✓

Intake Received

Save this reference ID. You'll need it to check your status and for your telehealth visit.

What happens next

Our team reviews your submission (typically within 2 hours)
You'll receive an email with a link to schedule your telehealth evaluation
A board-certified physician will conduct your video visit
Your certification documents are completed and delivered same-day

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