Fitness for work / Sick note

Please allow 2 working days before receiving the MED3 Certificate.

Title

First Names

Surname

Date of BirthDD/MM/YYYY

NHS Number (if known)

Your Contact Details

Home Address

Postcode

Telephone

Mobile

E-mail Address

Details

Start date

Finish date (if known)

Have you had a fit / sick note for this condition before?

If yes, please provide details of the previous note and why you require an additional note

If you have not had a note previously, provide details of your condition and why you require a fit / sick note

Are you fit for work as long as there are alterations to your workplace (e.g. adaptations to the workplace or working hours)?

If yes, please provide details

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