Sick Note Request Sick Note Request Online form What is your first name?What is your last name?Date of birth DD slash MM slash YYYY Your gender Male Female Other Your address: Street Address Optional Address Line 2 Optional City Optional ZIP / Postal Code Optional Email addressFirst date not at work due to this illness: DD slash MM slash YYYY Have you self-certified for 7 days Yes No Start date of sick / fit note: DD slash MM slash YYYY End date for sick / fit note: * DD slash MM slash YYYY Describe your illness and why you need a sick / fit note:Are you happy for us to send you your sick/fit note digitally? * Yes No