Sick/Fit Note Request form Fit Note Request Form Name Date of Birth DD slash MM slash YYYY How long do you need a sick note for? When does your current sick note end? DD slash MM slash YYYY Do you have a follow up appointment booked? Yes No When? DD slash MM slash YYYY If this is your final sick note, what is your return to work date? DD slash MM slash YYYY How would you like to receive your sick note? Text Email Collected in person
