Sick / Fit Note – Evelyn Medical Centre

01433 621557 ddicb.admin.emc@nhs.net

Sick / Fit Note
Is this your first sick / fit note for this illness?

This is my first Sick / Fit note for this illnessI have already had a Sick / Fit note for this illness

How long have you been ill (including bank holidays and weekends)?

I have been ill for 7 days or lessI have been ill for more than 7 days

Sick / Fit Note Request
Name*

First Name Last Name
Date*

DayMonth Year
Date
Email*
example@example.com
First date you were not at work due to this illness:
Total number of days you were ill or state ongoing:
Describe your illness and why you need a Sick / Fit Note:

Self Certification Sick / Fit Note for less than 7 days

If you have been ill for 7 days or less you don’t need to see a Doctor. You can complete a Self Certification form yourself. However some employers insist on a Doctor’s note regardless. A Doctor’s note under these circumstances may involve a charge.

Many employers have their own self-certification forms. If your employer doesn’t have its own form you can download the Self Certification Form. Please print it, fill it in and hand it in to your employer. You do not need to see a Doctor.

Self Certification Form (PDF)

Should be Empty: