Sick Note Form – Old Mill Surgery

If you have already had a Sick Note (Fit Note) for this illness, or you have already been reviewed by one of our team regarding the relevant illness, your doctor may not need to see you to issue an additional Sick Note.

Please note that you may be contacted by the GP to discuss the request. Otherwise, if your request is approved we will send it securely to your chosen method of delivery (Text/Email). We aim to complete the whole process within 2 working days.

Please do not write any clinical queries on this form. Any clinical queries or request for appointments via this form will be discarded. To make an appointment either book online via the NHS app/Patient access or by calling reception 02476 382554. We will start to process your form by the next working day but it may take up to 2 working days to complete. Please DO NOT call before 2 working days as you will not receive a status update from reception or the administrative team. If you are NOT a registered patient then your form will be discarded.

Please note, Sick note requests are also available via our Rapid Health Service HERE

Sick Note (New & Renewal)

Name
First Last
Date of Birth*
Contact number (preferably mobile)*
Do you need to extend a current sick note or get a new sick note?*
- Extend current note
- New sick note
Which doctor last reviewed you?*
Please enter the date you would like the sick note to start from*
PLEASE NOTE: The date selected cannot be in the future, doing so may cause delays or cancellation of your form.
Please enter how long you would like the sick note for*
Reason for sickness extension?*
Please define the reason you are unable to work
Sometimes temporary changes to your work can help in the recovery process. Please select the option below which you feel best applies*
Adaptations required
How would you like this sick note delivered?*
- Email (if you select this option an email box will appear below)
- Text (a mobile phone number entry box will appear upon selection of this option)
Your email address*
Mobile Number*
Consent*
Please note that no medical information or questions will be responded to. The data you supply on this form will be stored on our website, which is hosted by a third party, until it has been processed by the practice. The data will be used lawfully, in accordance with the Data Protection Act 2018, which gives you the right to know what information is held about you, and sets out rules to make sure that this information is handled properly. The practice privacy policy can be viewed on this website.
I agree to the privacy policy.