Fit To Return to Work Certificate Form

Personal Information

Step 1 of 3

First name

Last name

E-mail

Phone

Date of Birth required

Address

City

County

ZIP / Postal Code

Employer/Organisation Name:

What is your Job Role?

Please fill in the required fields.

Medical Condition

Step 2 of 3

What is the main reason you are choosing our medical certificate service?

Please specify your reason

What was the reason for your illness or why were you unfit for work?

How many days have you missed work?

Are you fully recovered? (Please consider this carefully, as partial recovery may still allow a return to work in some cases)

YesNo

Have you been following the recommended treatment plan for your condition?

YesNo

Are you experiencing any of the following conditions? Please check any that apply:

Recent surgery, especially abdominal or chest surgeryRecent heart attack or strokeUncontrolled hypertensioEar or sinus infectionsSevere respiratory diseaseInfectious diseasesInfectious diseases Deep vein thrombosis or risk of thromboembolismPregnancy complications or late-stage pregnancyOther

Have you been able to perform activities of daily living without difficulty?

YesNo

Are you currently taking any medications that may affect your ability to work?

YesNo

Are you fit to perform all the tasks involved in your role?

YesNo

I confirm that all my answers are true and I am completely responsible for them.

Please fill in the required fields.

Invalid File.

Update Variation

Step 3 of 3

Name	Price
Fit To Return to Work Certificate - Express (2-4 hrs)	€25.00
Fit To Return to Work Certificate - Standard (Within 24 hrs)	€20.00

Please fill in the required fields.

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Personal Information

Medical Condition

Update Variation