Sick / Fit Note Request

For the first 7 days of illness, you can self-certify and do not require a Med3 Fit Note. A note covering for this period would be private work and is chargeable, please call the surgery if requiring a private 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. We will contact you to let you know when your Sick/Fit Note will be ready to be emailed/collected or we may contact you to arrange an appointment.

Last Updated: 09/01/2023

Sick/Fit Note Request

Full Name *

Date of Birth *

Phone Number

Email Address *

Is this request for a new note or an extension? *

New note (Following 7 day self-certification)

Extension

When do you require the note to commence? For new notes this will be the 8th day, following 7 days self-certification *

When do you require the note to cover you until? *

Please provide a description on why you are requiring a fit note *

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. *

I consent to the practice collecting and storing my data from this form

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Sick / Fit Note Request

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