Fitness to Work Request Form

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 certificate will be sent to you within a week.

Fitness to Work Request Form

The Doctor may not necessarily issue a Fit to Work Certificate following this request. We may need to contact you for more information before this can be issued. Please leave 72 hours for completion of your certificate. Fitness to Work Certificates can also be backdated.

Full Name

Date of Birth

Telephone Number

Reason for Absence / Request

When do you need your line dated from?

What time period are you requesting?

1 week

2 weeks

3 weeks

4 weeks

This form is protected by reCAPTCHA and the Google Privacy Policy and Terms of Service apply.

Page last reviewed: 09 March 2026
Page created: 04 July 2025

Cookies on the Pathhead Medical Centre website

Fitness to Work Request Form

Fitness to Work Request Form

Fitness to Work Request Form