Medical Sick Note (Fit Note) Request Form(For non-NHS private medical certificate requests) Name * First Name Last Name Email * Phone * (###) ### #### Date Of Birth * MM DD YYYY Address * Address 1 Address 2 City State/Province Zip/Postal Code Country Gender * Male Female First day you were unable to work * MM DD YYYY Last day you were (or expect to be) unable to work * MM DD YYYY Are you still currently unwell or unable to work? * Yes No What condition or symptoms do you need a note for? * Please provide a short description of your symptoms and how they affected your ability to work Employer name (if applicable) Do you need your note to be backdated? * Yes No Do you need the note to be addressed to your employer, university, or another organisation? * Employer University Other No – personal copy only If yes, please enter the name of the organisation Have you been admitted to hospital during this period of illness? * Yes No Do you have a condition that has not yet been assessed or diagnosed by a healthcare professional? * Yes No Are you requesting a fit note for a mental health condition that has not been discussed with a professional? * Yes No Consent & Confirmation * I understand this is a private service and not an NHS sick note. I confirm I am requesting a note for an illness that genuinely impacted my ability to work. I understand false declarations may result in refusal of service. I consent to this information being reviewed by a prescribing clinician. I confirm all information provided is accurate and complete. Thank you. A clinician will review your request shortly. If approved, you’ll receive a signed medical certificate by email.
