Request a sick cert for work

THIS SERVICE IS FOR PATIENTS OF KINGSFORD MEDICAL ONLY

You must be seen by a GP to receive a sick note or illness benefit certificate, however if you have been seen in our practice for this illness already and need to request a sick cert for work purposes please fill in the form below and submit it. Your cert will be emailed to you within 2 working days.

Please note if you require a Social Welfare cert you will also need to collect an IB1 form from reception to complete and return to the Department of Social Protection.

First Name

Last Name

Date of Birth

Please use format as shown

PPS Number

PPS is required for a sick cert

Mobile Number

Email

Address

From Date

Please enter the 1st date of sick leave

Return to work Date

Date going back to work

Reason

Please enter the reason for sick leave

Other info

Please tick to confirm that you are a patient of Kingsford Medical, if you are not our patient your request will be deleted

I am a patient of Kingsford Medical

I am not a patient of Kingsford Medical

By using this form you will be sending personal/sensitive information about yourself across the Internet. Please read our privacy policy to discover how we protect and manage your submitted data. Whilst every effort is made to keep this information secure, you should be aware that we cannot offer any guarantees of absolute privacy. If this matter concerns you then you should use another method of contacting the practice.

Request a sick cert for work

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