TAIN & DISTRICT MEDICAL GROUP - SICK LINE REQUEST FORM

TAIN & DISTRICT MEDICAL GROUP - SICK LINE REQUEST FORM

PLEASE NOTE - ALL BOXES MUST BE COMPLETED, OTHERWISE THIS FORM WILL BE RETURNED TO YOU

TDMG SICK LINE

NAME

DATE OF BIRTH
For example, 15 3 1984

Day

Month

Year

CONTACT PHONE NUMBER

WHAT IS YOUR JOB TITLE?

PLEASE OUTLINE YOUR DUTIES BELOW -

IS THIS A FIRST SICK LINE OR AN EXTENSION OF AN EXISTING SICK LINE?

IF THIS IS YOUR FIRST SICK LINE HAVE YOUR SELF CERTIFIED FOR THE FIRST 7 DAYS?

WHAT IS THE REASON FOR YOUR INABILITY TO WORK? (please give specific details about your illness/injury)

HOW HAS YOUR ILLNESS/ INJURY AFFECTED YOUR ABILITY TO DO YOUR JOB (based on your duties detailed above) -

WHAT TYPE OF SICK LINE DO YOU REQUIRE?

WHICH DATE WOULD YOU LIKE THE SICK LINE TO START FROM? Please note we cannot forward sick lines, however, we can backdate them -
For example, 15 3 1984

Day

Month

Year

PLEASE INDICATE THE EXPECTED LENGTH OF TIME OFF REQUIRED (eg 1 week, 1 month)

PLEASE INDICATE HOW YOU WOULD PREFER TO COLLECT THE SICK LINE

COLLECT FROM RECEPTION

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Page last reviewed: 07 May 2026
Page created: 07 May 2026