Requesting an additional Sick 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. Please complete this form. We will contact you to let you know when you can collect your Sick Note or we may contact you to arrange an appointment.

Please Note – once you have submitted this information, any reply or acknowledgement from us will be sent to the email address you provide at top of the form. This response may include personal and sensitive information about you. We therefore strongly advise that you provide a personal email address that only you have access to. If you do not wish for us to communicate with you via email, please do not use this form and call us instead.

Sick Note Request

Sick Note Request

If you are human, leave this field blank.

Section

Is this your first sick/fit note for this episode of illness? *

Yes

No

Describe your illness and why you need a Sick Note: *

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

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

When should the sick/fit note start? (It is not possible to use a future start date): *

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

When should the sick/fit note end? (please note this may be amended by the clinician): *

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

Can your employer do anything to help you return to work sooner?

E.g. work from home or reduced hours or tasks

You may need an appointment to be assessed before we can issue your fit note, we will contact you to arrange if this is the case. Otherwise, we will send the fit note to the email address you provided at the top of this form.