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Fit (Sick) Note

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All questions marked with a * are mandatory

Do you need a sick note for coming out of hospital or following outpatient attendance?: *

If you are likely to need a sick note when you come out of hospital or following outpatient attendance, please ask the doctor treating you in hospital to provide you with one before you leave.

If you have forgotten to do this, please contact the hospital and ask for a sick note to be posted or texted to you.

You are unable to continue to the next step (see above). : *

Fit (Sick) Note

Your doctor will not provide a sick note for the first 7 days of your illnes - you will need to self-certify your illness. A sick note will normally be issued from day 8.

If you have been sick for more than 7 days, ensure you supply a sufficient summary or update of your condition so that your GP can justify the legal requirement of this form.

Please confirm you have been sick for more than 7: *

If you have been ill for 7 days or less you don’t need to see a Doctor.

You can complete a Self Certification form yourself.
If your employer doesn’t have its own form your can complete the Employee's Statement of Sickness (SC2) form online.
When you’ve filled in the form give it to your employer, it will help them decide if you can get Statutory Sick Pay. Keep a copy for your own information.

Some employers insist on a Doctor’s note regardless.

A Doctors note under these circumstances may involve a charge.
Please contact reception in these circumstances.

Have you already had a note about this?: *

Important

If you do not provide sufficient information there may be a delay in responding to your request. If this is an extension request, then please provide detail on how the condition is still affecting you, any changes in your condition, and any action you are taking to return to work. If you feel that your condition prevents you from working long-term, then please still provide an update so that we can confirm the extension is valid.

(eg: Could you work from home, do fewer hours, or do different tasks?)

You are unable to continue to the next step (see above). : *

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Personal Details

Please provide your details to help us find your record. If you are filling this in on behalf of someone else, please enter their details.

Please double check you've entered the correct email address

May be used to identify you

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Confirmation

Please check the details are correct

Name:
Date of Birth (yyyy-mm-dd):
Phone Number:
Email Address:

Have you already had a note about this?
Your Answer:

Tell us briefly about your illness or medical problem.
Your Answer:

When would you like the note to start? When do you think you can return to work?
Your Answer:

If possible, is there anything your employer could do to help you return sooner?
Your Answer:

How should we contact you?: *

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Privacy Consent

This form collects personal and medical information about you and we use this information to allow the practice team to contact you.
Please read our Privacy Policy to discover how we protect and manage your submitted data.

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