Sick (fit) note request

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Is this your first sick/fit note for this episode of illness? *

Yes

No

Describe your illness and why you need a Sick Note:

First date you were not at work due to this illness:

Please use this date format: DD/MM/YYYY.

When should the sick/fit note start? (It is not possible to use a future start date): *

Please use this date format: DD/MM/YYYY.

When should the sick/fit note end? (please note this may be amended by the clinician): *

Please use this date format: DD/MM/YYYY.

Can your employer do anything to help you return to work sooner?

E.g. work from home or reduced hours or tasks

You may need an appointment to be assessed before we can issue your fit note, we will contact you to arrange if this is the case. Otherwise, we will send the fit note to the email address you provided at the top of this form.

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