Requesting an additional Sick / Fit Note

If you have already had a Sick Note (Fit Note) for this illness your Doctor may not need to see you to issue an additional Sick Note. To avoid delay please provide as much detail so the GP can authorise a note if appropriate. In some circumstances, you may be asked to arrange a formal appointment.

Last Updated: 18/09/2021

Sick/Fit Note Request

FIRST AND LAST NAME

Which site are you registered at?

Meadowside Surgery

Yew Tree Surgery

Park Surgery

Tanworth Lane Surgery

Village Surgery

Knowle Surgery

Date of Birth
For example, 15 3 1984

Day

Month

Year

Phone Number

Email Address (optional)
Additional Sick/Fit Not Request

FIRST DATE YOU WERE NOT WORK DUE TO THIS ILLNESS
For example, 15 3 1984

Day

Month

Year

TOTAL NUMBER OF DAYS YOU WERE ILL OR STATE ONGOING

DESCRIBE YOUR ILLNESS AND WHY YOU NEED A SICK / FIT NOTE - Please provide as much detail to avoid delay i.e. the nature of the illness, the impact it is having on you and when you expect to return to work. If the information is unsatisfactory, you may be asked to arrange a formal GP appointment.

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

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.

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Requesting an additional Sick / Fit Note

Sick/Fit Note Request

Additional Sick/Fit Not Request