PLEASE NOTE: THIS FORM IS FOR THE CONTINUATION OF AN EXISTING FIT NOTE – If you require a first time fit note, please phone in for an on the day telephone appointment with a GP.

Fit notes will be ready to collect 3 working days after being requested. We are not able to post these out.

Please note that due to overall demand on services we will only contact you about your fit note if there is a problem or the doctor would like you to make an appointment. If you do not hear from us, your fit note will be ready in 3 working days. For example, if you request a fit note on Monday morning it will be ready to collect on Thursday morning.

Sick/Fit Note request form

Please complete this form to tell us about your illness and we will direct you to the most appropriate form or service.

Sick / Fit Note Request with Intelligence

Are you self-isolating because you, or someone you live with, has symptoms of coronavirus? *

Yes

Isolation Note from 111

Please check the NHS guidance on self-isolating here www.nhs.uk/conditions/coronavirus-covid-19/self-isolation-advice/.

You can get an isolation note from 111 online to give to your employer. You do not need a sick note from the surgery.

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

Yes

No, I have already had a sick / fit note for this illness

First Sick / Fit Note

Have you completed a self certificate? *

Yes

If you have been sick for more than four days in a row you can self–certify your illness using a SC2 form available online from HMRC.

Many employers have their own self-certification forms. You do not need to see a Doctor.

Requesting an additional Sick / Fit Note

If you have already had a Note for this illness your Doctor may not need to see you to issue an additional Note. Please complete this form. We will contact you to let you know when your Note is ready or we may contact you for more information.

Doctor’s Sick / Fit Note for more than 7 days

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 surgery may call you for more information.

If you have already been seen by your Doctor about this illness your certificate will be sent to you within a week.

Please complete the form below.

Name of doctor who gave you last sickline *

Your details

First Name *

Last Name *

Email *

Enter Email

Date of birth *

Please use format day/month/year e.g. 12/05/1979

Phone Number *

Your Illness

Sickline start date *

Number of days you have been unwell or state 'ONGOING' *

You should specify your full period of illness including weekends and holidays, not just days off work.

What is the reason you cannot work? *

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

Do you intend to be off for 4 weeks or longer? *

Yes

Date you intend to return to work *

How long do you think you may need to be off for? *

Privacy Policy

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. 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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Self-Certificate

If you have been sick for more than four days in a row, but less than seven, you can self–certify your illness using a SC2 form. You can obtain this form from your employer or by visiting the HMRC website. If you are unwell for more than four days you are advised to arrange an appointment to see a Doctor to assess your fitness to work.

Statement of Fitness for Work

The Doctor will provide you with a Statement of Fitness for Work (‘Fit Note’) if you are still not well enough to work. Your employer will most likely request this statement as evidence to support payment of Statutory Sick Pay (SSP).

Further information is available at the Direct.Gov website.

Private Certificates

If you or your employer require further information concerning your period(s) of illness , then your Doctor may require to issue you with a letter. Please note that a charge may apply for this service. Please check with our reception desk.

Practices Portland/Hurlford	01563 522411
NHS 24	111

Sickness Certificates