Sick (fit) note request

Date you want the sick/fit note to start:

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

Total number of days you were ill or state ongoing:

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

Do you already have a Sick / Fit note regarding this illness?

Yes

No

Name of GP to deal with the form:

Are you appealing your benefit claim?

Do you want a Fit to Return to Work note?

Date you wish to return to work:

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

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