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    {"id":213,"date":"2023-10-06T10:17:50","date_gmt":"2023-10-06T09:17:50","guid":{"rendered":"https:\/\/nhs-demo.surgeryweb.org.uk\/?page_id=213"},"modified":"2026-08-05T13:51:55","modified_gmt":"2026-08-05T12:51:55","slug":"sick-fit-notes","status":"publish","type":"page","link":"https:\/\/surgerywebtemp.org.uk\/l81041\/sick-fit-notes\/","title":{"rendered":"Sick (fit) notes"},"content":{"rendered":"<h3>If you&#8217;re sick for less than 7 days<\/h3>\n<p>If you have been ill for 7 days or less you don\u2019t need to see a Doctor. You can complete a Self-Certification form yourself. However some employers insist on a Doctor\u2019s note regardless. A Doctors note under these circumstances involves a charge of \u00a310.<\/p>\n<p>Many employers have their own self-certification forms. If your employer doesn\u2019t have its own form you can download the Self Certification Form. Please print it, fill it in and hand it in to your employer. You do not need to see a Doctor.<\/p>\n<h3>If you&#8217;re sick for more than 7 days<\/h3>\n<p>If you have been ill for more than 7 days you will need a doctor\u2019s certificate. These certificates are called \u2018Fitness to Work\u2019 Certificates.<\/p>\n<p>The doctor may call you or arrange for an appointment.<\/p>\n<p>If you have already been seen by your Doctor about this illness your certificate will be sent to you within a week.<\/p>\n<h3>Requesting an additional Sick\/Fit note<\/h3>\n<p>If you have already had a Sick Note (Fit Note) for this illness your Doctor may not need to see you to issue an additional Sick Note. Please complete this form. We will contact you to let you know when you can collect your Sick \/ Fit Note or we may contact you to arrange an appointment.<\/p>\n<script>\nvar gform;gform||(document.addEventListener(\"gform_main_scripts_loaded\",function(){gform.scriptsLoaded=!0}),document.addEventListener(\"gform\/theme\/scripts_loaded\",function(){gform.themeScriptsLoaded=!0}),window.addEventListener(\"DOMContentLoaded\",function(){gform.domLoaded=!0}),gform={domLoaded:!1,scriptsLoaded:!1,themeScriptsLoaded:!1,isFormEditor:()=>\"function\"==typeof InitializeEditor,callIfLoaded:function(o){return!(!gform.domLoaded||!gform.scriptsLoaded||!gform.themeScriptsLoaded&&!gform.isFormEditor()||(gform.isFormEditor()&&console.warn(\"The use of gform.initializeOnLoaded() is deprecated in the form editor context and will be removed in Gravity Forms 3.1.\"),o(),0))},initializeOnLoaded:function(o){gform.callIfLoaded(o)||(document.addEventListener(\"gform_main_scripts_loaded\",()=>{gform.scriptsLoaded=!0,gform.callIfLoaded(o)}),document.addEventListener(\"gform\/theme\/scripts_loaded\",()=>{gform.themeScriptsLoaded=!0,gform.callIfLoaded(o)}),window.addEventListener(\"DOMContentLoaded\",()=>{gform.domLoaded=!0,gform.callIfLoaded(o)}))},hooks:{action:{},filter:{}},addAction:function(o,r,e,t){gform.addHook(\"action\",o,r,e,t)},addFilter:function(o,r,e,t){gform.addHook(\"filter\",o,r,e,t)},doAction:function(o){gform.doHook(\"action\",o,arguments)},applyFilters:function(o){return gform.doHook(\"filter\",o,arguments)},removeAction:function(o,r){gform.removeHook(\"action\",o,r)},removeFilter:function(o,r,e){gform.removeHook(\"filter\",o,r,e)},addHook:function(o,r,e,t,n){null==gform.hooks[o][r]&&(gform.hooks[o][r]=[]);var d=gform.hooks[o][r];null==n&&(n=r+\"_\"+d.length),gform.hooks[o][r].push({tag:n,callable:e,priority:t=null==t?10:t})},doHook:function(r,o,e){var t;if(e=Array.prototype.slice.call(e,1),null!=gform.hooks[r][o]&&((o=gform.hooks[r][o]).sort(function(o,r){return o.priority-r.priority}),o.forEach(function(o){\"function\"!=typeof(t=o.callable)&&(t=window[t]),\"action\"==r?t.apply(null,e):e[0]=t.apply(null,e)})),\"filter\"==r)return e[0]},removeHook:function(o,r,t,n){var e;null!=gform.hooks[o][r]&&(e=(e=gform.hooks[o][r]).filter(function(o,r,e){return!!(null!=n&&n!=o.tag||null!=t&&t!=o.priority)}),gform.hooks[o][r]=e)}});\n<\/script>\n\n                <div class='gf_browser_gecko gform_wrapper gravity-theme gform-theme--no-framework' data-form-theme='gravity-theme' data-form-index='0' id='gform_wrapper_17' style='display:none'><div id='gf_17' class='gform_anchor' tabindex='-1'><\/div>\n                        <div class='gform_heading'>\n                            <h2 class=\"gform_title\">Sick Note Request<\/h2>\n                        <\/div><form method='post' enctype='multipart\/form-data' target='gform_ajax_frame_17' id='gform_17'  action='\/l81041\/wp-json\/wp\/v2\/pages\/213#gf_17' data-formid='17' novalidate>\n        <div id='gf_progressbar_wrapper_17' class='gf_progressbar_wrapper' data-start-at-zero=''>\n        \t<p class=\"gf_progressbar_title\">Step <span class='gf_step_current_page'>1<\/span> of <span class='gf_step_page_count'>3<\/span><span class='gf_step_page_name'><\/span>\n        \t<\/p>\n            <div class='gf_progressbar gf_progressbar_blue' aria-hidden='true'>\n                <div class='gf_progressbar_percentage percentbar_blue percentbar_33' style='width:33%;'><span>33%<\/span><\/div>\n            <\/div><\/div>\n                        <div class='gform-body gform_body'><div id='gform_page_17_1' class='gform_page ' data-js='page-field-id-0' >\n\t\t\t\t\t<div class='gform_page_fields'><div id='gform_fields_17' class='c-form-list gform_fields top_label form_sublabel_below description_below validation_below'><fieldset id=\"field_17_3\" class=\"gfield nhsuk-form-group gfield--type-radio gfield--type-choice gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible gfield--choice-align-vertical\"  ><legend class='nhsuk-label gform-field-label' ><span class='gform-field-label__text'>Who are you completing this form for?<\/span>&nbsp;&nbsp;<span class=\"nhsuk-tag nhsuk-tag--grey\">Required<\/span><\/legend><div class='ginput_container ginput_container_radio nhsuk-radios'>\n\t\t\t<div class='gchoice nhsuk-radios__item gchoice_17_3_0'>\n\t\t\t\t\t<input class='gfield-choice-input nhsuk-radios__input' name='input_3' type='radio' value='Yourself'  id='choice_17_3_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label class=\"nhsuk-label nhsuk-radios__label\" for='choice_17_3_0' id='label_17_3_0' class='gform-field-label gform-field-label--type-inline'>Yourself<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice nhsuk-radios__item gchoice_17_3_1'>\n\t\t\t\t\t<input class='gfield-choice-input nhsuk-radios__input' name='input_3' type='radio' value='Someone else'  id='choice_17_3_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label class=\"nhsuk-label nhsuk-radios__label\" for='choice_17_3_1' id='label_17_3_1' class='gform-field-label gform-field-label--type-inline'>Someone else<\/label>\n\t\t\t<\/div><\/div><\/fieldset><fieldset id=\"field_17_12\" class=\"gfield nhsuk-form-group gfield--type-name gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='nhsuk-label gform-field-label nhsuk-label_before_complex' ><span class='gform-field-label__text'>What is the patients name?<\/span>&nbsp;&nbsp;<span class=\"nhsuk-tag nhsuk-tag--grey\">Required<\/span><\/legend><div class='ginput_complex ginput_container ginput_container--name no_prefix has_first_name no_middle_name has_last_name no_suffix gf_name_has_2 ginput_container_name gform-grid-row' id='input_17_12'>\n                            \n                            <span id='input_17_12_3_container' class='name_first gform-grid-col gform-grid-col--size-auto' >\n                                                    <input type='text' class='nhsuk-input '  name='input_12.3' id='input_17_12_3' value=''   aria-required='true'     \/>\n                                                    <label for='input_17_12_3' class='gform-field-label gform-field-label--type-sub '>First<\/label>\n                                                <\/span>\n                            \n                            <span id='input_17_12_6_container' class='name_last gform-grid-col gform-grid-col--size-auto' >\n                                                    <input type='text' class='nhsuk-input '  name='input_12.6' id='input_17_12_6' value=''   aria-required='true'     \/>\n                                                    <label for='input_17_12_6' class='gform-field-label gform-field-label--type-sub '>Last<\/label>\n                                                <\/span>\n                            \n                        <\/div><\/fieldset><fieldset id=\"field_17_13\" class=\"gfield nhsuk-form-group gfield--type-date gfield--input-type-date gfield--input-type-datedropdown gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='nhsuk-label gform-field-label' ><span class='gform-field-label__text'>What is the patients date of birth?<\/span>&nbsp;&nbsp;<span class=\"nhsuk-tag nhsuk-tag--grey\">Required<\/span><\/legend><div id='input_17_13' class='ginput_container ginput_complex gform-grid-row'><div class='gfield_date_dropdown_day ginput_container ginput_container_date gform-grid-col' id='input_17_13_2_container'><label for='input_17_13_2' class='gform-field-label gform-field-label--type-sub hidden_sub_label screen-reader-text'>Day<\/label><select class=\"nhsuk-select\" name='input_13[]' id='input_17_13_2'   aria-required='true'  ><option value=''>Day<\/option><option value='1' >1<\/option><option value='2' >2<\/option><option value='3' >3<\/option><option value='4' >4<\/option><option value='5' >5<\/option><option value='6' >6<\/option><option value='7' >7<\/option><option value='8' >8<\/option><option value='9' >9<\/option><option value='10' >10<\/option><option value='11' >11<\/option><option value='12' >12<\/option><option value='13' >13<\/option><option value='14' >14<\/option><option value='15' >15<\/option><option value='16' >16<\/option><option value='17' >17<\/option><option value='18' >18<\/option><option value='19' >19<\/option><option value='20' >20<\/option><option value='21' >21<\/option><option value='22' >22<\/option><option value='23' >23<\/option><option value='24' >24<\/option><option value='25' >25<\/option><option value='26' >26<\/option><option value='27' >27<\/option><option value='28' >28<\/option><option value='29' >29<\/option><option value='30' >30<\/option><option value='31' >31<\/option><\/select><\/div><div class='gfield_date_dropdown_month ginput_container ginput_container_date gform-grid-col' id='input_17_13_1_container'><label for='input_17_13_1' class='gform-field-label gform-field-label--type-sub hidden_sub_label screen-reader-text'>Month<\/label><select class=\"nhsuk-select\" name='input_13[]' id='input_17_13_1'   aria-required='true'  ><option value=''>Month<\/option><option value='1' >1<\/option><option value='2' >2<\/option><option value='3' >3<\/option><option value='4' >4<\/option><option value='5' >5<\/option><option value='6' >6<\/option><option value='7' >7<\/option><option value='8' >8<\/option><option value='9' >9<\/option><option value='10' >10<\/option><option value='11' >11<\/option><option value='12' >12<\/option><\/select><\/div><div class='gfield_date_dropdown_year ginput_container ginput_container_date gform-grid-col' id='input_17_13_3_container'><label for='input_17_13_3' class='gform-field-label gform-field-label--type-sub hidden_sub_label screen-reader-text'>Year<\/label><select class=\"nhsuk-select\" name='input_13[]' id='input_17_13_3'   aria-required='true'  ><option value=''>Year<\/option><option value='2027' >2027<\/option><option value='2026' >2026<\/option><option value='2025' >2025<\/option><option value='2024' >2024<\/option><option value='2023' >2023<\/option><option value='2022' >2022<\/option><option value='2021' >2021<\/option><option value='2020' >2020<\/option><option value='2019' >2019<\/option><option value='2018' >2018<\/option><option value='2017' >2017<\/option><option value='2016' >2016<\/option><option value='2015' >2015<\/option><option value='2014' >2014<\/option><option value='2013' >2013<\/option><option value='2012' >2012<\/option><option value='2011' >2011<\/option><option value='2010' >2010<\/option><option value='2009' >2009<\/option><option value='2008' >2008<\/option><option value='2007' >2007<\/option><option value='2006' >2006<\/option><option value='2005' >2005<\/option><option value='2004' >2004<\/option><option value='2003' >2003<\/option><option value='2002' >2002<\/option><option value='2001' >2001<\/option><option value='2000' >2000<\/option><option value='1999' >1999<\/option><option value='1998' >1998<\/option><option value='1997' >1997<\/option><option value='1996' >1996<\/option><option value='1995' >1995<\/option><option value='1994' >1994<\/option><option value='1993' >1993<\/option><option value='1992' >1992<\/option><option value='1991' >1991<\/option><option value='1990' >1990<\/option><option value='1989' >1989<\/option><option value='1988' >1988<\/option><option value='1987' >1987<\/option><option value='1986' >1986<\/option><option value='1985' >1985<\/option><option value='1984' >1984<\/option><option value='1983' >1983<\/option><option value='1982' >1982<\/option><option value='1981' >1981<\/option><option value='1980' >1980<\/option><option value='1979' >1979<\/option><option value='1978' >1978<\/option><option value='1977' >1977<\/option><option value='1976' >1976<\/option><option value='1975' >1975<\/option><option value='1974' >1974<\/option><option value='1973' >1973<\/option><option value='1972' >1972<\/option><option value='1971' >1971<\/option><option value='1970' >1970<\/option><option value='1969' >1969<\/option><option value='1968' >1968<\/option><option value='1967' >1967<\/option><option value='1966' >1966<\/option><option value='1965' >1965<\/option><option value='1964' >1964<\/option><option value='1963' >1963<\/option><option value='1962' >1962<\/option><option value='1961' >1961<\/option><option value='1960' >1960<\/option><option value='1959' >1959<\/option><option value='1958' >1958<\/option><option value='1957' >1957<\/option><option value='1956' >1956<\/option><option value='1955' >1955<\/option><option value='1954' >1954<\/option><option value='1953' >1953<\/option><option value='1952' >1952<\/option><option value='1951' >1951<\/option><option value='1950' >1950<\/option><option value='1949' >1949<\/option><option value='1948' >1948<\/option><option value='1947' >1947<\/option><option value='1946' >1946<\/option><option value='1945' >1945<\/option><option value='1944' >1944<\/option><option value='1943' >1943<\/option><option value='1942' >1942<\/option><option value='1941' >1941<\/option><option value='1940' >1940<\/option><option value='1939' >1939<\/option><option value='1938' >1938<\/option><option value='1937' >1937<\/option><option value='1936' >1936<\/option><option value='1935' >1935<\/option><option value='1934' >1934<\/option><option value='1933' >1933<\/option><option value='1932' >1932<\/option><option value='1931' >1931<\/option><option value='1930' >1930<\/option><option value='1929' >1929<\/option><option value='1928' >1928<\/option><option value='1927' >1927<\/option><option value='1926' >1926<\/option><option value='1925' >1925<\/option><option value='1924' >1924<\/option><option value='1923' >1923<\/option><option value='1922' >1922<\/option><option value='1921' >1921<\/option><option value='1920' >1920<\/option><\/select><\/div><\/div><\/fieldset><fieldset id=\"field_17_14\" class=\"gfield nhsuk-form-group gfield--type-radio gfield--type-choice gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible gfield--choice-align-vertical\"  ><legend class='nhsuk-label gform-field-label' ><span class='gform-field-label__text'>What is the patients sex?<\/span>&nbsp;&nbsp;<span class=\"nhsuk-tag nhsuk-tag--grey\">Required<\/span><\/legend><div class='ginput_container ginput_container_radio nhsuk-radios'>\n\t\t\t<div class='gchoice nhsuk-radios__item gchoice_17_14_0'>\n\t\t\t\t\t<input class='gfield-choice-input nhsuk-radios__input' name='input_14' type='radio' value='Male'  id='choice_17_14_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label class=\"nhsuk-label nhsuk-radios__label\" for='choice_17_14_0' id='label_17_14_0' class='gform-field-label gform-field-label--type-inline'>Male<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice nhsuk-radios__item gchoice_17_14_1'>\n\t\t\t\t\t<input class='gfield-choice-input nhsuk-radios__input' name='input_14' type='radio' value='Female'  id='choice_17_14_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label class=\"nhsuk-label nhsuk-radios__label\" for='choice_17_14_1' id='label_17_14_1' class='gform-field-label gform-field-label--type-inline'>Female<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice nhsuk-radios__item gchoice_17_14_2'>\n\t\t\t\t\t<input class='gfield-choice-input nhsuk-radios__input' name='input_14' type='radio' value='gf_other_choice'  id='choice_17_14_2' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label class=\"nhsuk-label nhsuk-radios__label\" for='choice_17_14_2' id='label_17_14_2' class='gform-field-label gform-field-label--type-inline'>Other<\/label><br \/><input id='input_17_14_other' class='gchoice_other_control' name='input_14_other' type='text' value='Other' aria-label='Other Choice, please specify'  disabled='disabled' \/>\n\t\t\t<\/div><\/div><\/fieldset><div id=\"field_17_15\" class=\"gfield nhsuk-form-group gfield--type-text gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='nhsuk-label gform-field-label' for='input_17_15'><span class='gform-field-label__text'>What is the patients postcode?<\/span>&nbsp;&nbsp;<span class=\"nhsuk-tag nhsuk-tag--grey\">Required<\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_15' id='input_17_15' type='text' value='' class='large nhsuk-input '     aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/div><fieldset id=\"field_17_16\" class=\"gfield nhsuk-form-group gfield--type-radio gfield--type-choice gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible gfield--choice-align-vertical\"  ><legend class='nhsuk-label gform-field-label' ><span class='gform-field-label__text'>What is your relationship to the patient?<\/span>&nbsp;&nbsp;<span class=\"nhsuk-tag nhsuk-tag--grey\">Required<\/span><\/legend><div class='ginput_container ginput_container_radio nhsuk-radios'>\n\t\t\t<div class='gchoice nhsuk-radios__item gchoice_17_16_0'>\n\t\t\t\t\t<input class='gfield-choice-input nhsuk-radios__input' name='input_16' type='radio' value='Parent'  id='choice_17_16_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label class=\"nhsuk-label nhsuk-radios__label\" for='choice_17_16_0' id='label_17_16_0' class='gform-field-label gform-field-label--type-inline'>Parent<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice nhsuk-radios__item gchoice_17_16_1'>\n\t\t\t\t\t<input class='gfield-choice-input nhsuk-radios__input' name='input_16' type='radio' value='Guardian'  id='choice_17_16_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label class=\"nhsuk-label nhsuk-radios__label\" for='choice_17_16_1' id='label_17_16_1' class='gform-field-label gform-field-label--type-inline'>Guardian<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice nhsuk-radios__item gchoice_17_16_2'>\n\t\t\t\t\t<input class='gfield-choice-input nhsuk-radios__input' name='input_16' type='radio' value='Spouse'  id='choice_17_16_2' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label class=\"nhsuk-label nhsuk-radios__label\" for='choice_17_16_2' id='label_17_16_2' class='gform-field-label gform-field-label--type-inline'>Spouse<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice nhsuk-radios__item gchoice_17_16_3'>\n\t\t\t\t\t<input class='gfield-choice-input nhsuk-radios__input' name='input_16' type='radio' value='Carer'  id='choice_17_16_3' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label class=\"nhsuk-label nhsuk-radios__label\" for='choice_17_16_3' id='label_17_16_3' class='gform-field-label gform-field-label--type-inline'>Carer<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice nhsuk-radios__item gchoice_17_16_4'>\n\t\t\t\t\t<input class='gfield-choice-input nhsuk-radios__input' name='input_16' type='radio' value='Son'  id='choice_17_16_4' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label class=\"nhsuk-label nhsuk-radios__label\" for='choice_17_16_4' id='label_17_16_4' class='gform-field-label gform-field-label--type-inline'>Son<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice nhsuk-radios__item gchoice_17_16_5'>\n\t\t\t\t\t<input class='gfield-choice-input nhsuk-radios__input' name='input_16' type='radio' value='Daughter'  id='choice_17_16_5' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label class=\"nhsuk-label nhsuk-radios__label\" for='choice_17_16_5' id='label_17_16_5' class='gform-field-label gform-field-label--type-inline'>Daughter<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice nhsuk-radios__item gchoice_17_16_6'>\n\t\t\t\t\t<input class='gfield-choice-input nhsuk-radios__input' name='input_16' type='radio' value='Sibling'  id='choice_17_16_6' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label class=\"nhsuk-label nhsuk-radios__label\" for='choice_17_16_6' id='label_17_16_6' class='gform-field-label gform-field-label--type-inline'>Sibling<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice nhsuk-radios__item gchoice_17_16_7'>\n\t\t\t\t\t<input class='gfield-choice-input nhsuk-radios__input' name='input_16' type='radio' value='gf_other_choice'  id='choice_17_16_7' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label class=\"nhsuk-label nhsuk-radios__label\" for='choice_17_16_7' id='label_17_16_7' class='gform-field-label gform-field-label--type-inline'>Other<\/label><br \/><input id='input_17_16_other' class='gchoice_other_control' name='input_16_other' type='text' value='Other' aria-label='Other Choice, please specify'  disabled='disabled' \/>\n\t\t\t<\/div><\/div><\/fieldset><fieldset id=\"field_17_6\" class=\"gfield nhsuk-form-group gfield--type-name gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='nhsuk-label gform-field-label nhsuk-label_before_complex' ><span class='gform-field-label__text'>What is your name?<\/span>&nbsp;&nbsp;<span class=\"nhsuk-tag nhsuk-tag--grey\">Required<\/span><\/legend><div class='ginput_complex ginput_container ginput_container--name no_prefix has_first_name no_middle_name has_last_name no_suffix gf_name_has_2 ginput_container_name gform-grid-row' id='input_17_6'>\n                            \n                            <span id='input_17_6_3_container' class='name_first gform-grid-col gform-grid-col--size-auto' >\n                                                    <input type='text' class='nhsuk-input '  name='input_6.3' id='input_17_6_3' value=''   aria-required='true'     \/>\n                                                    <label for='input_17_6_3' class='gform-field-label gform-field-label--type-sub '>First<\/label>\n                                                <\/span>\n                            \n                            <span id='input_17_6_6_container' class='name_last gform-grid-col gform-grid-col--size-auto' >\n                                                    <input type='text' class='nhsuk-input '  name='input_6.6' id='input_17_6_6' value=''   aria-required='true'     \/>\n                                                    <label for='input_17_6_6' class='gform-field-label gform-field-label--type-sub '>Last<\/label>\n                                                <\/span>\n                            \n                        <\/div><\/fieldset><fieldset id=\"field_17_7\" class=\"gfield nhsuk-form-group gfield--type-date gfield--input-type-date gfield--input-type-datedropdown gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='nhsuk-label gform-field-label' ><span class='gform-field-label__text'>What is your date of birth?<\/span>&nbsp;&nbsp;<span class=\"nhsuk-tag nhsuk-tag--grey\">Required<\/span><\/legend><div id='input_17_7' class='ginput_container ginput_complex gform-grid-row'><div class='gfield_date_dropdown_day ginput_container ginput_container_date gform-grid-col' id='input_17_7_2_container'><label for='input_17_7_2' class='gform-field-label gform-field-label--type-sub hidden_sub_label screen-reader-text'>Day<\/label><select class=\"nhsuk-select\" name='input_7[]' id='input_17_7_2'   aria-required='true'  ><option value=''>Day<\/option><option value='1' >1<\/option><option value='2' >2<\/option><option value='3' >3<\/option><option value='4' >4<\/option><option value='5' >5<\/option><option value='6' >6<\/option><option value='7' >7<\/option><option value='8' >8<\/option><option value='9' >9<\/option><option value='10' >10<\/option><option value='11' >11<\/option><option value='12' >12<\/option><option value='13' >13<\/option><option value='14' >14<\/option><option value='15' >15<\/option><option value='16' >16<\/option><option value='17' >17<\/option><option value='18' >18<\/option><option value='19' >19<\/option><option value='20' >20<\/option><option value='21' >21<\/option><option value='22' >22<\/option><option value='23' >23<\/option><option value='24' >24<\/option><option value='25' >25<\/option><option value='26' >26<\/option><option value='27' >27<\/option><option value='28' >28<\/option><option value='29' >29<\/option><option value='30' >30<\/option><option value='31' >31<\/option><\/select><\/div><div class='gfield_date_dropdown_month ginput_container ginput_container_date gform-grid-col' id='input_17_7_1_container'><label for='input_17_7_1' class='gform-field-label gform-field-label--type-sub hidden_sub_label screen-reader-text'>Month<\/label><select class=\"nhsuk-select\" name='input_7[]' id='input_17_7_1'   aria-required='true'  ><option value=''>Month<\/option><option value='1' >1<\/option><option value='2' >2<\/option><option value='3' >3<\/option><option value='4' >4<\/option><option value='5' >5<\/option><option value='6' >6<\/option><option value='7' >7<\/option><option value='8' >8<\/option><option value='9' >9<\/option><option value='10' >10<\/option><option value='11' >11<\/option><option value='12' >12<\/option><\/select><\/div><div class='gfield_date_dropdown_year ginput_container ginput_container_date gform-grid-col' id='input_17_7_3_container'><label for='input_17_7_3' class='gform-field-label gform-field-label--type-sub hidden_sub_label screen-reader-text'>Year<\/label><select class=\"nhsuk-select\" name='input_7[]' id='input_17_7_3'   aria-required='true'  ><option value=''>Year<\/option><option value='2027' >2027<\/option><option value='2026' >2026<\/option><option value='2025' >2025<\/option><option value='2024' >2024<\/option><option value='2023' >2023<\/option><option value='2022' >2022<\/option><option value='2021' >2021<\/option><option value='2020' >2020<\/option><option value='2019' >2019<\/option><option value='2018' >2018<\/option><option value='2017' >2017<\/option><option value='2016' >2016<\/option><option value='2015' >2015<\/option><option value='2014' >2014<\/option><option value='2013' >2013<\/option><option value='2012' >2012<\/option><option value='2011' >2011<\/option><option value='2010' >2010<\/option><option value='2009' >2009<\/option><option value='2008' >2008<\/option><option value='2007' >2007<\/option><option value='2006' >2006<\/option><option value='2005' >2005<\/option><option value='2004' >2004<\/option><option value='2003' >2003<\/option><option value='2002' >2002<\/option><option value='2001' >2001<\/option><option value='2000' >2000<\/option><option value='1999' >1999<\/option><option value='1998' >1998<\/option><option value='1997' >1997<\/option><option value='1996' >1996<\/option><option value='1995' >1995<\/option><option value='1994' >1994<\/option><option value='1993' >1993<\/option><option value='1992' >1992<\/option><option value='1991' >1991<\/option><option value='1990' >1990<\/option><option value='1989' >1989<\/option><option value='1988' >1988<\/option><option value='1987' >1987<\/option><option value='1986' >1986<\/option><option value='1985' >1985<\/option><option value='1984' >1984<\/option><option value='1983' >1983<\/option><option value='1982' >1982<\/option><option value='1981' >1981<\/option><option value='1980' >1980<\/option><option value='1979' >1979<\/option><option value='1978' >1978<\/option><option value='1977' >1977<\/option><option value='1976' >1976<\/option><option value='1975' >1975<\/option><option value='1974' >1974<\/option><option value='1973' >1973<\/option><option value='1972' >1972<\/option><option value='1971' >1971<\/option><option value='1970' >1970<\/option><option value='1969' >1969<\/option><option value='1968' >1968<\/option><option value='1967' >1967<\/option><option value='1966' >1966<\/option><option value='1965' >1965<\/option><option value='1964' >1964<\/option><option value='1963' >1963<\/option><option value='1962' >1962<\/option><option value='1961' >1961<\/option><option value='1960' >1960<\/option><option value='1959' >1959<\/option><option value='1958' >1958<\/option><option value='1957' >1957<\/option><option value='1956' >1956<\/option><option value='1955' >1955<\/option><option value='1954' >1954<\/option><option value='1953' >1953<\/option><option value='1952' >1952<\/option><option value='1951' >1951<\/option><option value='1950' >1950<\/option><option value='1949' >1949<\/option><option value='1948' >1948<\/option><option value='1947' >1947<\/option><option value='1946' >1946<\/option><option value='1945' >1945<\/option><option value='1944' >1944<\/option><option value='1943' >1943<\/option><option value='1942' >1942<\/option><option value='1941' >1941<\/option><option value='1940' >1940<\/option><option value='1939' >1939<\/option><option value='1938' >1938<\/option><option value='1937' >1937<\/option><option value='1936' >1936<\/option><option value='1935' >1935<\/option><option value='1934' >1934<\/option><option value='1933' >1933<\/option><option value='1932' >1932<\/option><option value='1931' >1931<\/option><option value='1930' >1930<\/option><option value='1929' >1929<\/option><option value='1928' >1928<\/option><option value='1927' >1927<\/option><option value='1926' >1926<\/option><option value='1925' >1925<\/option><option value='1924' >1924<\/option><option value='1923' >1923<\/option><option value='1922' >1922<\/option><option value='1921' >1921<\/option><option value='1920' >1920<\/option><\/select><\/div><\/div><\/fieldset><fieldset id=\"field_17_8\" class=\"gfield nhsuk-form-group gfield--type-radio gfield--type-choice gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible gfield--choice-align-vertical\"  ><legend class='nhsuk-label gform-field-label' ><span class='gform-field-label__text'>What is your sex?<\/span>&nbsp;&nbsp;<span class=\"nhsuk-tag nhsuk-tag--grey\">Required<\/span><\/legend><div class='ginput_container ginput_container_radio nhsuk-radios'>\n\t\t\t<div class='gchoice nhsuk-radios__item gchoice_17_8_0'>\n\t\t\t\t\t<input class='gfield-choice-input nhsuk-radios__input' name='input_8' type='radio' value='Male'  id='choice_17_8_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label class=\"nhsuk-label nhsuk-radios__label\" for='choice_17_8_0' id='label_17_8_0' class='gform-field-label gform-field-label--type-inline'>Male<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice nhsuk-radios__item gchoice_17_8_1'>\n\t\t\t\t\t<input class='gfield-choice-input nhsuk-radios__input' name='input_8' type='radio' value='Female'  id='choice_17_8_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label class=\"nhsuk-label nhsuk-radios__label\" for='choice_17_8_1' id='label_17_8_1' class='gform-field-label gform-field-label--type-inline'>Female<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice nhsuk-radios__item gchoice_17_8_2'>\n\t\t\t\t\t<input class='gfield-choice-input nhsuk-radios__input' name='input_8' type='radio' value='gf_other_choice'  id='choice_17_8_2' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label class=\"nhsuk-label nhsuk-radios__label\" for='choice_17_8_2' id='label_17_8_2' class='gform-field-label gform-field-label--type-inline'>Other<\/label><br \/><input id='input_17_8_other' class='gchoice_other_control' name='input_8_other' type='text' value='Other' aria-label='Other Choice, please specify'  disabled='disabled' \/>\n\t\t\t<\/div><\/div><\/fieldset><div id=\"field_17_9\" class=\"gfield nhsuk-form-group gfield--type-text gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='nhsuk-label gform-field-label' for='input_17_9'><span class='gform-field-label__text'>What is your postcode?<\/span>&nbsp;&nbsp;<span class=\"nhsuk-tag nhsuk-tag--grey\">Required<\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_9' id='input_17_9' type='text' value='' class='large nhsuk-input '     aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_17_10\" class=\"gfield nhsuk-form-group gfield--type-phone gfield--phone-format-international gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='nhsuk-label gform-field-label' for='input_17_10'><span class='gform-field-label__text'>What is your phone number?<\/span>&nbsp;&nbsp;<span class=\"nhsuk-tag nhsuk-tag--grey\">Required<\/span><\/label><div class='ginput_container ginput_container_phone'><input name='input_10' id='input_17_10' type='tel' value='' class='large nhsuk-input '   aria-required=\"true\" aria-invalid=\"false\"    \/><\/div><\/div><div id=\"field_17_11\" class=\"gfield nhsuk-form-group gfield--type-email gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='nhsuk-label gform-field-label' for='input_17_11'><span class='gform-field-label__text'>What is your email address?<\/span>&nbsp;&nbsp;<span class=\"nhsuk-tag nhsuk-tag--grey\">Required<\/span><\/label><div class='ginput_container ginput_container_email'>\n                            <input name='input_11' id='input_17_11' type='email' value='' class='large nhsuk-input '    aria-required=\"true\" aria-invalid=\"false\"  \/>\n                        <\/div><\/div><\/div>\n                    <\/div>\n                    <div class='gform-page-footer gform_page_footer top_label'>\n                         <button type='button' id='gform_next_button_17_17' class='nhsuk-button' onclick='gform.submission.handleButtonClick(this);' data-submission-type='next' >Next<\/button> \n                    <\/div>\n                <\/div>\n                <div id='gform_page_17_2' class='gform_page' data-js='page-field-id-17' style='display:none;'>\n                    <div class='gform_page_fields'>\n                        <div id='gform_fields_17_2' class='c-form-list gform_fields top_label form_sublabel_below description_below validation_below'><fieldset id=\"field_17_20\" class=\"gfield nhsuk-form-group gfield--type-date gfield--input-type-date gfield--input-type-datedropdown gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='nhsuk-label gform-field-label' ><span class='gform-field-label__text'>First date you were not at work due to this illness<\/span>&nbsp;&nbsp;<span class=\"nhsuk-tag nhsuk-tag--grey\">Required<\/span><\/legend><div id='input_17_20' class='ginput_container ginput_complex gform-grid-row'><div class='gfield_date_dropdown_day ginput_container ginput_container_date gform-grid-col' id='input_17_20_2_container'><label for='input_17_20_2' class='gform-field-label gform-field-label--type-sub hidden_sub_label screen-reader-text'>Day<\/label><select class=\"nhsuk-select\" name='input_20[]' id='input_17_20_2'   aria-required='true'  ><option value=''>Day<\/option><option value='1' >1<\/option><option value='2' >2<\/option><option value='3' >3<\/option><option value='4' >4<\/option><option value='5' >5<\/option><option value='6' >6<\/option><option value='7' >7<\/option><option value='8' >8<\/option><option value='9' >9<\/option><option value='10' >10<\/option><option value='11' >11<\/option><option value='12' >12<\/option><option value='13' >13<\/option><option value='14' >14<\/option><option value='15' >15<\/option><option value='16' >16<\/option><option value='17' >17<\/option><option value='18' >18<\/option><option value='19' >19<\/option><option value='20' >20<\/option><option value='21' >21<\/option><option value='22' >22<\/option><option value='23' >23<\/option><option value='24' >24<\/option><option value='25' >25<\/option><option value='26' >26<\/option><option value='27' >27<\/option><option value='28' >28<\/option><option value='29' >29<\/option><option value='30' >30<\/option><option value='31' >31<\/option><\/select><\/div><div class='gfield_date_dropdown_month ginput_container ginput_container_date gform-grid-col' id='input_17_20_1_container'><label for='input_17_20_1' class='gform-field-label gform-field-label--type-sub hidden_sub_label screen-reader-text'>Month<\/label><select class=\"nhsuk-select\" name='input_20[]' id='input_17_20_1'   aria-required='true'  ><option value=''>Month<\/option><option value='1' >1<\/option><option value='2' >2<\/option><option value='3' >3<\/option><option value='4' >4<\/option><option value='5' >5<\/option><option value='6' >6<\/option><option value='7' >7<\/option><option value='8' >8<\/option><option value='9' >9<\/option><option value='10' >10<\/option><option value='11' >11<\/option><option value='12' >12<\/option><\/select><\/div><div class='gfield_date_dropdown_year ginput_container ginput_container_date gform-grid-col' id='input_17_20_3_container'><label for='input_17_20_3' class='gform-field-label gform-field-label--type-sub hidden_sub_label screen-reader-text'>Year<\/label><select class=\"nhsuk-select\" name='input_20[]' id='input_17_20_3'   aria-required='true'  ><option value=''>Year<\/option><option value='2027' >2027<\/option><option value='2026' >2026<\/option><option value='2025' >2025<\/option><option value='2024' >2024<\/option><option value='2023' >2023<\/option><option value='2022' >2022<\/option><option value='2021' >2021<\/option><option value='2020' >2020<\/option><option value='2019' >2019<\/option><option value='2018' >2018<\/option><option value='2017' >2017<\/option><option value='2016' >2016<\/option><option value='2015' >2015<\/option><option value='2014' >2014<\/option><option value='2013' >2013<\/option><option value='2012' >2012<\/option><option value='2011' >2011<\/option><option value='2010' >2010<\/option><option value='2009' >2009<\/option><option value='2008' >2008<\/option><option value='2007' >2007<\/option><option value='2006' >2006<\/option><option value='2005' >2005<\/option><option value='2004' >2004<\/option><option value='2003' >2003<\/option><option value='2002' >2002<\/option><option value='2001' >2001<\/option><option value='2000' >2000<\/option><option value='1999' >1999<\/option><option value='1998' >1998<\/option><option value='1997' >1997<\/option><option value='1996' >1996<\/option><option value='1995' >1995<\/option><option value='1994' >1994<\/option><option value='1993' >1993<\/option><option value='1992' >1992<\/option><option value='1991' >1991<\/option><option value='1990' >1990<\/option><option value='1989' >1989<\/option><option value='1988' >1988<\/option><option value='1987' >1987<\/option><option value='1986' >1986<\/option><option value='1985' >1985<\/option><option value='1984' >1984<\/option><option value='1983' >1983<\/option><option value='1982' >1982<\/option><option value='1981' >1981<\/option><option value='1980' >1980<\/option><option value='1979' >1979<\/option><option value='1978' >1978<\/option><option value='1977' >1977<\/option><option value='1976' >1976<\/option><option value='1975' >1975<\/option><option value='1974' >1974<\/option><option value='1973' >1973<\/option><option value='1972' >1972<\/option><option value='1971' >1971<\/option><option value='1970' >1970<\/option><option value='1969' >1969<\/option><option value='1968' >1968<\/option><option value='1967' >1967<\/option><option value='1966' >1966<\/option><option value='1965' >1965<\/option><option value='1964' >1964<\/option><option value='1963' >1963<\/option><option value='1962' >1962<\/option><option value='1961' >1961<\/option><option value='1960' >1960<\/option><option value='1959' >1959<\/option><option value='1958' >1958<\/option><option value='1957' >1957<\/option><option value='1956' >1956<\/option><option value='1955' >1955<\/option><option value='1954' >1954<\/option><option value='1953' >1953<\/option><option value='1952' >1952<\/option><option value='1951' >1951<\/option><option value='1950' >1950<\/option><option value='1949' >1949<\/option><option value='1948' >1948<\/option><option value='1947' >1947<\/option><option value='1946' >1946<\/option><option value='1945' >1945<\/option><option value='1944' >1944<\/option><option value='1943' >1943<\/option><option value='1942' >1942<\/option><option value='1941' >1941<\/option><option value='1940' >1940<\/option><option value='1939' >1939<\/option><option value='1938' >1938<\/option><option value='1937' >1937<\/option><option value='1936' >1936<\/option><option value='1935' >1935<\/option><option value='1934' >1934<\/option><option value='1933' >1933<\/option><option value='1932' >1932<\/option><option value='1931' >1931<\/option><option value='1930' >1930<\/option><option value='1929' >1929<\/option><option value='1928' >1928<\/option><option value='1927' >1927<\/option><option value='1926' >1926<\/option><option value='1925' >1925<\/option><option value='1924' >1924<\/option><option value='1923' >1923<\/option><option value='1922' >1922<\/option><option value='1921' >1921<\/option><option value='1920' >1920<\/option><\/select><\/div><\/div><\/fieldset><div id=\"field_17_21\" class=\"gfield nhsuk-form-group gfield--type-text gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='nhsuk-label gform-field-label' for='input_17_21'><span class='gform-field-label__text'>Total number of days you were ill or state ongoing<\/span>&nbsp;&nbsp;<span class=\"nhsuk-tag nhsuk-tag--grey\">Required<\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_21' id='input_17_21' type='text' value='' class='large 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