Fit Note Application Form

For Patients who have already had a sick note for this period of illness.

Please be advised completion of this form is not a guarantee of a fit note, the GP may still need to discuss things further with you.

If there are not any issues with the form then please collect your fit note from the surgery 48 hours after you have completed this form.

Please advise your employer that you have consulted your doctor and will be able to provide them with a fit note in due course.

If you are going back to work with no alterations please remember that you do not need a return to work fit note.

* Required Field

Full Name*:

Date of Birth*:

Contact Phone Number*:

Surgery*:

- Select - Rosebery Medical Centre Outwoods Medical Centre Forest Edge Medical Centre

First Date of Sickness*:

Number of days sick note is required for (please specify full period of illness including days where you would not normally be at work)*:

What is the reason that you cannot work?*

Are you looking to return to work with alterations that your employer would like including on the form? What changes/ plans have been agreed?*

If adaptions were made to your role could you return to work earlier, e.g. altered duties, phased return?*

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