Requesting an additional Sick Note

If you have already had a Sick Note for this illness your Doctor may not need to see you to issue an additional Sick Note. Please complete this form. Please contact the surgery after 2 working days to confirm if your sick/Fit note is ready for collection.

Sick Note Request

Sick Note Request

If you are human, leave this field blank.

Full Name: *

Date of Birth: *

Please use this date format: DD/MM/YYYY.

Phone Number:

Email Address: *

Any responses we send will go to this email address.

First date you were not at work due to this illness:

Please use this date format: DD/MM/YYYY.

Total number of days you were ill or state ongoing:

Start date of new Sick/Fit Note being requested: *

Please use this date format: DD/MM/YYYY.

End date of new Sick/Fit Note being requested: *

Please use this date format: DD/MM/YYYY.

The new date of your new sick note will be the date after the last sick note finished e.g. if your certificate expired on the 17th December, you will need to request the new note from the 18th December.

Describe your illness and why you need a Sick / Fit Note: