Private Sick Note Request – Old Mill Surgery

Please complete this form for a private sick note request.

This will cost £25 and will take up to 2 working days to process.

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 will 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. This service is only for patients registered at the surgery aged 16 and over; and for parents or legal guardians of children. Forms must be completed in the UK due to GDPR regulations.

Name
First Last
Date of Birth*
Contact number (preferably mobile)*
If your request is approved you will receive a text to confirm it is ready to collect.
Reason for sickness?*
Please define the reason you are unable to work
Please enter the first date of sickness*
DD slash MM slash YYYY
Please enter the last date of sickness*
DD slash MM slash YYYY
Coronavirus symptoms?
Please note if you experience a fever (>37.8C) or a persistent cough (>4 hours) do not attend to collect your sick note. Instead self-isolate for 7 days & collect once this is over. Visit the NHS Coronavirus page for more information.
I confirm I am happy to pay the £25 charge for this private sick note.*
- Yes I agree to pay £25
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.

Coronavirus symptoms?