Template for an employer to get information about an employee's health when it's relevant to their job. Free to use.
You must get permission from the employee before contacting their doctor.
You can copy and paste the template text into an email or document.
To: [Doctor's name]
From: [Your name]
[Name of your organisation]
[Address of your organisation]
If you're unable to provide the requested information quickly, please reply to confirm you've received this.
Dear [doctor's name]
I am writing for information about your patient [name of employee], who lives at [address of employee].
I am a/an* [your role] at [name of your organisation]. Your patient works as a/an* [employee's job title] at the organisation.
I have attached the employee’s permission for me to make this request. They [do/do not] want to see the report before you send it to me.
I would like information in order to [manage sick pay / plan work / support the employee].
I would like information about:
[List the things you’re asking about. For example:
- their absence from work, including absence dates
- their health condition, such as a broken wrist]
Their role involves:
[List any employee tasks or responsibilities the condition might affect. For example:
- standing for long periods
- heavy lifting
- working evenings
- using a keyboard
I would like to know:
[List any other information you need. For example:
- the condition's impact on carrying out their tasks or responsibilities
- whether the employee is disabled
- reasonable adjustments that might be needed
- a likely date the employee will return to work
- if a phased return to work, change of duties or other support might help the employee]
Let me know if I need to pay a fee for this information.
Please reply [by email / by post - a stamped addressed envelope is enclosed].
[Your telephone number]
[Your email address]
*delete as necessary
Download this template
- Download this template in Microsoft Word format (DOCX, 16KB)
- Download this template in Open Document format (ODT, 9KB)
If you need the template in a different format, email firstname.lastname@example.org.