Travel Letter Request Form

First Name *

Last Name *

DOB *

Mobile Number *

Email Address *

Address

Your Doctors Name *

Medication you are currently taking *

Travel Start Date *

Return Date *

Travel Destination *

Stop Over/s *

Please confirm you have read and agree to terms in our Privacy Policy *

Note: Obtaining a travel letter online will be up to the discretion of the treating psychiatrist and may take up to a week for a letter to be issued. Letters may incur a fee or in some cases.

For security please complete the check below *