Requesting an additional sick/fit note

If you have already had a sick/fit note for this illness or condition, your doctor may not need to see you to issue an extenstion. 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.

Last Updated: 21/11/2023

Sick/Fit Note Request

Full Name *

Date of Birth *

Phone Number

Email Address *

Additional Sick/Fit Not Request

Tell us the first date you were not at work because of this illness *

Describe your illness or condition and why you need a sick/fit note. *

How many days were you away from work? Or is the illness still ongoing? *

If the illness is still ongoing, how long do you think you will be away from work?

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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Requesting an additional sick/fit note

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