Requesting an additional/extension Doctor’s Sick/Fit Note

Please use this form to request an additional/extension Doctor’s Sick/Fit note.

If you have already had a Sick Note (Fit Note) for an illness your Doctor may not need to see you to issue an additional Sick Note. Your Sick Note will be sent to you within a week.
Full Name*
Date of Birth*
Mobile Phone Number*
Date you would like your sick/fit note to start*
DD slash MM slash YYYY
Date you would like your sick/fit note to end*
DD slash MM slash YYYY
Describe your illness and why you need a Sick/Fit note*
Consent*
I agree to the privacy policy.
Please note that no medical information or questions will be responded to. The data you supply on this form will be stored on our website, which is hosted by a third party, until it has been processed by the practice. The data will be used lawfully, in accordance with the Data Protection Act 2018, which gives you the right to know what information is held about you, and sets out rules to make sure that this information is handled properly. The practice privacy policy can be viewed on this website.