Back To Work

Employee Name *

Employee Email Address *

They will receive a copy of this form

Absence Start Date *

Absence End Date *

Reason For Absence *

Is the Employee capable of returning to work and working effectively? *

Yes

No

In the short term

In the long term

How lack of capability is to be dealt with

Strategy for avoiding further absences for the same or similar reasons

Any agreement reached in order to avoid the possibility of further supervision or disciplinary action due to repeated absence in the future (if any)

Other manager’s comments on this incidence of absence

Date

Signed by Supervisor *

Clear

Ear, Nose, & Throat

Infections & Minor Illness

Lifestyle

Skin

Vaccinations

Women's Health

Men’s Health

Aesthetics

Blood Pressure Check

Chickenpox

COVID-19 Vaccination

Cryotherapy

Earwax Removal

Family Planning

Flu Vaccination

Hair Loss

Hepatitis B

HPV

Menopause

Mole Check

Pneumococcal Vaccine

Private GP Services

Shingles Vaccination

Travel Vaccination Clinic

Vitamin B12 Treatment

Weight Management

Yellow Fever Vaccination

Book Appointment

Contact

Pricelist

NHS Services

Contraceptive Pill Repeat Supply

Ear Infection

(1-17 Years)

Impetigo Sores

(1+)

Infected Bug Bites

(1+)

NHS Cardiovascular Health Check

NHS Stop Smoking Support

Shingles Rash

(18+)

Sinusitis

(12+)

Sore Throat

(5+)

Urine Infection

(Women 16-64 Yrs)

Private Services

Cardiovascular Health Check

Erectile Dysfunction Treatment

Period Delay

Weight Loss Pre-Assessment

Book Appointment

Contact

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