Who are you completing this form for?
For example, on behalf of a child or dependent
What is your name?
What is your date of birth?
For example, 31 3 1980
What is your sex?
As recorded on your medical record
The one used to register with your GP
Anyone else with access to your email account may see responses sent to you
Please use this date format: DD/MM/YYYY.
Include holidays and weekends, not just days off work.

Certificates must be requested on the date you need them to start from – we cannot postdate a certificate and they cannot be requested in advance.

Is the condition still on-going?