Request an additional Sick / Fit Note

If you have already had a Sick Note, also known as a Fit Note, for this illness, your doctor may not need to see you to issue an additional Sick Note.

Please complete the form below. We will contact you to let you know when you can collect your Sick Note or Fit Note.

We may also contact you to arrange an appointment if this is needed.

Please complete the form fully

If you do not complete all form details, your request may be rejected by the surgery. Please provide as much detail as possible so the GP can assess your request for a Fit Note.

About You

Full Name

Todays date

For example, 15 3 1984

Day

Month

Year

Date of Birth

For example, 15 3 1984

Day

Month

Year

Mobile Number/Contact Number

Email Address

ADDITIONAL SICK/FIT NOT REQUEST

What is your Job?

What is still preventing you from working?

Have your sought any help to return back to work?

FIRST DATE YOU WERE NOT WORK DUE TO THIS ILLNESS (DD/MM/YYYY)

For example, 15 3 1984

Day

Month

Year

TOTAL NUMBER OF DAYS YOU WERE ILL?

DESCRIBE YOUR ILLNESS AND WHY YOU NEED A SICK / FIT NOTE

PLEASE STATE HOW MANY DAYS/WEEKS YOU REQUIRE YOUR SICK NOTE FOR?

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.

Sea

Níl

Old Station Surgery

Old Station Surgery

Request an additional Sick / Fit Note

Please complete the form fully

About You

ADDITIONAL SICK/FIT NOT REQUEST