Test Form Sick Note Request Online form What is your first name?What is your last name?Date of birth DD slash MM slash YYYY Your gender Male Female Other Your address: Street Address Address Line 2 ZIP / Postal Code Email address OptionalContact numberHave you self-certified your sickness absence for 7 days? Yes No If you are off work for 7 days or less, you do not need to give your employer a fit note or other proof of sickness from a healthcare professional. When you return to work, your employer can ask you to confirm they’ve been off sick. This is called ‘self-certification’. We will not issue a sick/fit note unless you have already done this.Start date of sick / fit note: DD slash MM slash YYYY Your existing sick/fit note expires the midnight of the end date indicated. E.g. Current sick/fit note end date: Thursday 30th January 2025, this will expire at midnight on Thursday night, your new sick/fit note request should be from Friday 31st January 2025. We cannot post-date sick/fit notes, please only request fit notes starting today or in the past. End date for sick / fit note: * DD slash MM slash YYYY Describe your illness and why you need a sick / fit note:Are you happy for us to send you your sick/fit note digitally? * Yes No