Doctor’s Certificate / Sick Line Request

Our clinical team can only provide a Fit Note (also known as a sick line, Med3 or Doctor's certificate) if you have been unable to attend work due to ill health for more than 7 consecutive calendar days, or if your request is for the continuation of a current Fit Note.

You are required to self certify for the first 7 consecutive calendar days of any illness. If you request a Fit Note for less than 7 days then your request for a Fit Note will not be be processed as you are required to self certify for this period of time. You should contact your line manager or HR department to arrange this.

Please provide as much detail as possible when completeing the undernoted form. If our clinical team are satisfied with the details you have provided your Fit Note will be issued, however, if they require further information, you will be contacted by our admin or clinical team. Once your Fit Note is issued it will either be posted to your home address, emailed to you or left at reception for you to collect.

If your request is for a continuation of your current Fit Note then please provide as much detail as possible and a projection of how much more time you think you will need to be off for. If you are unsure, and feel you need to speak to a clinician about this then please request this in the 'describe your illness' section in this form.

Please note that there are only a certain amount sick lines completed per day, due to restrictions on administrative time. This means that it may be several working days before your sick line is completed, but it will be back dated to your requested date. Once completed it will be sent to yourself via your chosen method.

Last Updated: 04/01/2024

Your Details

Full Name *

Date of Birth *

Home Address

Phone Number *

EMAIL ADDRESS

Sick/Fit Note

IS THIS YOUR FIRST SICK LINE IN THIS ILLNESS, OR A CONTINUATION? *

FIRST SICK LINE

CONTINUATION OF A PREVIOUS LINE

FIRST DATE YOU WERE NOT AT WORK DUE TO THIS ILLNESS

I CONFIRM I HAVE SELF CERTIFIED FROM:

UNTIL:

What date does your sick line need to start? Please state how long you need your sick line to be (e.g. for 1 month). Please state particular dates if necessary. *

DESCRIBE YOUR ILLNESS AND WHY YOU NEED A SICK LINE *

HOW DO YOU WISH TO RECEIVE YOUR SICK LINE? *

POST TO HOME ADDRESS

COLLECT FROM SCOTSTOWN RECEPTION

EMAILED TO ABOVE ADDRESS

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Doctor’s Certificate / Sick Line Request

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