Sick (fit) note request

What is your name?

First name

Last name

What is your date of birth?

For example, 31 3 1980

Day

Month

Year

What is your sex?

As recorded on your medical record

Male

Female

Other

What is your postcode?

The one used to register with your GP

What is your phone number?

What is your email address?

Anyone else with access to your email account may see responses sent to you

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:

How long have you been off work?

Have you completed a SC2 self certification form?

Yes

No

Date certificate is needed:

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

How long do you need the certificate for?

Do we have a hospital discharge letter?

Yes

No

Do you have a diagnosis?

Yes

No

What is your diagnosis?

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

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