Sick note request form – Middleway Surgery

Is this your first sick/fit note for this illness?(Required)

YES this is my first Sick/Fit Note for this illness

NO this is not my first Sick/Fit Note for this illness

Have you seen a doctor about your condition?(Required)

Yes

Which doctor or health professional did you see?(Required)

How long have you been ill?(Required)

I have been ill for 7 days or less

I have been ill for more than 7 days

Self-Certification sick/fit note for less than 7 days

If you have been ill for 7 days or less you don’t need to see a doctor. You can complete a Self-Certification form yourself. However some employers insist on a doctor’s note regardless. A doctor’s note under these circumstances may involve a charge.

Many employers have their own self-certification forms. If your employer doesn’t have its own form you can download the Self Certification Form. Please print it, fill it in and hand it in to your employer. You do not need to see a doctor.

Download a self-certification form to give to your employer

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 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.

Your full name(Required)

Date of birth(Required)

Phone number(Required)

Email address(Required)

Enter Email Confirm Email

Date you would like your sick/fit note to start(Required)

Date you would like your sick/fit note to finish(Required)

Describe your illness and why you need a sick/fit note(Required)

Requesting an additional sick/fit 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 / Fit Note or we may contact you to arrange an appointment.

Your full name(Required)

Date of birth(Required)

Phone number

Email address(Required)

Enter Email Confirm Email

Date you would like your additional sick/fit note to start(Required)

Date you would like your additional sick/fit note to finish(Required)

Describe your illness and why you need a sick/fit note(Required)

Are there any reasonable adjustments your employer could make to help you return to work sooner?

For example altered hours, working from home, amended duties, making workplace adaptations.

Consent and terms

This form is for non-urgent enquiries and will take up to 3 working days for a response.

Not for urgent medical help(Required)

Yes, I understand this form is NOT for urgent medical help

This field is for validation purposes and should be left unchanged.