Request for a Doctor’s Sick/Fit Note v2

If you have been ill for more than 7 days you will need a doctor’s certificate. These certificates are called ‘Fitness To Work’ Certificates. The doctor may call you or arrange for an appointment. If you have already been seen by your Doctor about this illness your certificate will be sent to you within a week.

Last Updated: 26/01/2024

Your Details

Full Name *

Date of Birth *

Phone Number

Email Address *

Sick/Fit Note

Please selectwhether you would like to be signed off work (a Not fit for work note) or would you like a note to say you could work if certain condiitions were met (a May be fit for work note) *

If you have picked a May be fit for work note please write what changes you would need to be able to work EG altered hours, amended duties, workplace adaptations

Please type the condition for which you need to be signed off work *

Please enter the dates you would like the note to start and end *

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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Request for a Doctor’s Sick/Fit Note v2

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