Copy of - MED3 - Doctor’s Sick/Fit Note for more than 7 days

If you have been ill for more than 7 days you will need a doctor’s certificate. These certificates are called ‘Fitness To Work’ Certificates. The doctor may call you or arrange for an appointment. If you have already been seen by your Doctor about this illness your form will be reviewed.

Your Details

Full Name

Date of Birth
For example, 15 3 1984

Day

Month

Year

Phone Number

Email Address
Sick/Fit Note

What is the medical reason as to why you are unfit for work?

IS THIS A NEW REQUEST FOR A SICKNOTE OR A CHANGE TO CURRENT SICKNOTE / RENEW, PLEASE SPECIFY:

ARE YOU CURRENTLY EMPLOYED? IF SO, PLEASE STATE WHAT JOB YOU DO?

HAVE YOU COMPLETED THE 7-DAY SELF CERTIFICATE?

WHAT DATE DID YOU START YOUR SELF CERTIFICATE?

HAVE YOU BEEN SEEN IN SURGERY OR OTHER SERVICES FOR THIS PROBLEM? EXAMPLE A&E, WALK IN CENTRE ETC. (PLEASE STATE DATE OF WHEN YOU WERE SEEN.)

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Page last reviewed: 20 January 2026
Page created: 06 April 2022

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Copy of - MED3 - Doctor’s Sick/Fit Note for more than 7 days

Copy of - MED3 - Doctor’s Sick/Fit Note for more than 7 days

Your Details

Sick/Fit Note