Charnwood Medical Group - G1

Do I need a Fit/ Sick note?

Fit Note Application Form

For Patients who have already had a sick note from the Practice (not hospital) for this period of illness.

Please do not request before two working days before your current note expires.

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*:

First Date of Sickness*:

What date do you need the fit note to start from?*

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?*

We are now able to text you a link to your mobile phone that will enable you to download your fit note online and save you coming to the surgery. You can then download it, save it, print it and email it to your place of work.

Yes please text me a link No I will collect a paper copy from the surgery

Fit Note Application Form v1.0 (PDF, 49 Kb)

Self Certification Form (PDF, 53 Kb)

Do I need a Fit/ Sick note?

Fit Note Application Form

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