Sick Note Request Sick Note Request Online form Phone OptionalThis field is for validation purposes and should be left unchanged.What is your first name?What is your last name?Date of birth MM slash DD slash YYYY Your gender Male Female Other Your address: Street Address Optional Address Line 2 Optional City Optional ZIP / Postal Code Optional Email addressStart date of sick / fit note: MM slash DD slash YYYY End date for sick / fit note: * MM slash DD 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