Fit Notes / Sick notes « Lockside Medical Centre

Request a Fit note/Sick note for work

Name(Required)

First Last

Date of birth(Required)

Phone(Required)

Is this:(Required)

A new episode of illness

An extension to an existing sick note

Please let us know what medical condition is preventing you from working.(Required)

If this is an extension to a Fit note, when does your current note run out?

Please tell us how your symptoms would make it hard for you to do your job at the moment. It is helpful if you tell us a little about your job.(Required)

Is there anything your employer could do to adapt your job so that you may be able to work in some capacity? This could be a change in role, adaptations or altered hours.(Required)

Yes/possibly

If you answered 'Yes/possibly', please give details

How long do you feel you will need to be off work?(Required)

This will be assessed by a GP who may contact you for a further assessment.

Receiving your Fit note(Required)

I am happy for the practice to text the Fit note to me

I would prefer to collect a paper version of the Fit note from the practice

Please tick one of these boxes. Our preference is to send it by text as this is better for the environment. If collecting in person, please allow 2 working days.

Is there anything else you need us to know with regard to your Fit note request?

Phone

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

Request a Fit note/Sick note for Universal credit/ESA

If you are not currently employed and need proof that you are too unwell to look for work then please use this form.