Sick Note - Old - Connected Telehealth

Patient Name:(Required)

Patient Date of Birth:(Required)

Patient Address:(Required)

Patient Email:(Required)

The above-named patient was consulted/recieved treatment on:(Required)

According to my assessment,the patient/employee was unfit for duty due to treatment or ill health from:(Required)

and may resume duties on:

Nature of illness:(Required)

Date Issued:(Required)

Time(Required)

For verification, call telephone:(Required)

Full Name:(Required)

Email Address:(Required)

Phone:(Required)

Qualification:(Required)

National Council Registration:(Required)

Practice Number:

Signature(Required)