Sick (fit) note request

Form summary

Is this your first sick note for this illness?

Yes, this is the first sick note

No, I need an additional sick note

First sick note

What date do you need the sick note to start?

For example, 31/03/1980

What date do you need the sick note to end?

For example, 31/03/1980

Additional sick note

What date does your current sick note end?

For example, 31/03/1980

What date do you need the new sick note to end?

For example, 31/03/1980

Why do you need a sick note?

For example, details about your illness or any adjustments

Terms and conditions

I confirm that this is not an emergency and understand the surgery cannot help while it is closed. If I need help right now, I will use the NHS 111 service. In an emergency, I will call 999 or go to A&E.

Tell us whether you accept cookies

Form summary

First sick note

Additional sick note