Sick/Fit Note Request Form

If you have been ill for more than 7 days, you can use this form to request a 'fit for work' certficate. The doctor may need to contact you to discuss your illness or ask to arrange a consultation. Please allow 5 working days for your request to be processed. Your sick/fit note will be emailed to you when completed.

Last Updated: 09/02/2024

Your Details

Full Name *

Date of Birth *

Home Address *

Phone Number *

Email Address *

The doctor may need to contact you to discuss your symptoms. You might be contacted by phone, SMS, or email. Your completed sick/fit note will be emailed to the address you have provided above. *

I consent to the practice contacting me by phone, SMS and/or email.

Sick/Fit Note

Is this a new request or extension of an existing sick note (fit note)? *

New request

Extension

First date you were not at work due to this illness *

End date required for sick/fit note (estimated) *

Please describe your illness and why you need a sick/fit note *

What is your occupation?

This form collects your name, date of birth, email, other personal information and medical details. This is to confirm you are registered with the practice, to allow the practice team to contact you and also to update your medical records held by the practice and our partners in the NHS. Please read our Privacy Policy to discover how we protect and manage your submitted data. *

I consent to the practice collecting and storing my data from this form.

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Sick/Fit Note Request Form

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