Fitness to Work Request Form

PLEASE COMPLETE THIS FORM IN FULL, providing as much detail as possible. failure to complete all the form details MAY result in your request being rejected. Your sick note will be ready to collect in the surgery, 3 working days after submission

Last Updated: 27/05/2022

Your Details

Full Name *

Date of Birth (DD/MM/YYYY) *

Address (Including Postcode) *

Contact Number *

Email Address *

Fitness to Work Information

Is this a New Request or Extension of an existing sicknote (fit note) *

New Sick Note

Follow on / Extension Sick Note

What is your occupation? *

Please tell us the Start Date required for this sick note (fit note) *

Please tell us the End Date required for this sick note (fit note) *

How long do you expect you'll be ill for? *

Please tell us why you need a sick note (fit note) Please provide as much information as possible *

DISCLOSURE - 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 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. By completing this form, you consent to the practice collecting and storing the data on this form.

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Fitness to Work Request Form

Further Information