Step 1

What is this leave from?

Please note: The Partner Doctors are currently unable to review requests for fitness for work certificates as part of your consultation outcome.

I am seeking
Please select a leave type.
The leave is from
Please select where the leave is from.
2 out of 5 steps complete

What is the main reason for this leave?

Tell your Partner Doctor what's wrong.

Please select a reason for the leave.
3 out of 5 steps complete

How long do you need this for?

If suitable, your Partner Doctor might change the end date based on what they believe is appropriate.

Please select a start date.
Please select valid end date.
4 out of 5 steps complete

Tell your Partner Doctor more

Please provide them as much detail as possible.

Please describe the timeline of your symptoms, the details of your symptoms, and if you would like anything specifically included on any documents you might receive as part of your outcome.

20 words minimum.

Please provide at least 20 words.
Optional file upload (Discharge papers, Doctor's letter, etc)
5 out of 5 steps complete

Your information

This information is needed to confirm your identity and to be included on any documents your Partner Doctor provides.

Please enter your date of birth.
We'll send any documents via SMS to this number in addition to email.

Review your details!

Please double check your details below. This will be included on any documents provided by your Partner Doctor and cannot be edited after submission.