Sick (fit) note request

Have you self-certified for the first 7 days of illness?

Yes

No (Please complete a self-certification for the first 7 days before requesting a sick note.)

Have you already had a Sick Note (Fit Note) for this illness? *

Yes

No

Sick Note (Fit Note) Expiry Date: *

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

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

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

Total number of days you were ill or state ongoing:

What date do you want the sick note to start from?

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

What date do you want the sick note to end on?

Please use this date format: DD/MM/YYYY. If ongoing, leave blank or state ‘ongoing’.

Describe your illness and why you need a Sick / Fit Note:

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