Sick Line Request Form

Sicklines will be ready to collect from the practice after 48 hours.

Sick line Request form

Did you know if you sign up for our Text Reminder Service, we can respond to your sick line request more efficiently? See our website under the appointments tile.

Name *

Date of Birth *

Contact Number *

What is your job title? *

Please outline the duties of your role below *

Is this a first sick line or an extension of an existing sick line? *

First

Extension

If this is your first sick line, have you self-certified for the first 7 days? *

Yes

What is the reason for your inability to work? (please give specific details of your injury / illness ) *

How has your illness/injury affected your ability to do your job based on your duties outlined above? *

What type of sick line do you require? *

Full absence from work

Phased return - Amended duties

Phased return- Amended hours

Which date would you like the sick line to start? (we cannot forward date sick lines, however we can backdate them) *

Please indicate the expected length of time off required (1 week, 1 month etc.) *

Sicklines will be ready to collect from the practice after 48 hours.

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Page last reviewed: 10 January 2024
Page created: 04 September 2020

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Sick Line Request Form

Sick Line Request Form

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