Sick Note Request Form

Sick Note Request

First Name: *

Surname: *

Date of birth: *

Contact Phone Number *

PLEASE BE AWARE YOU MUST ENTER THE PHONE NUMBER WITHOUT ANY SPACES E.G. 01751123456

Date your last sick note expired: *

Date you would like your sick note to start: *

Duration of cover you are requesting: *

Date of this request: *

Reason for sick note request - i.e. nature of illness/injury: *

If you believe you need your sick note to be ready sooner than 3 days from receipt of your request please provide your reason: *

Please note:

- Completing this request does not guarantee that a sick note will be issued.
- Your doctor will not issue a sick note in the first 7 days of any absence from work/illness. This period is covered by self-certification. Your employer should be able to provide you with a self-certification form.
- If the Doctor approves your request it will be ready for collection from Reception 3 working days following the receipt of your request.
- Sick notes cannot be signed before the date they are due to start, but they can be backdated. Therefore it is unlikely that your sick note needs to be available sooner than the 3 working days following your request. If you have any extenuating circumstances please detail them in the box above.