Fit note / Sick note Request

You can request a Fit / Sick note by either completing the form below or complete an online form using eConsult here.

The online forms should only be used if you have had a note for the condition before. If it is a new issue contact the surgery as you will need an appointment.

When do I need a fit / sick note?

7 days off sick or less

If you're off work sick for 7 days or less, your employer should not ask for medical evidence that you've been ill. Instead they can ask you to confirm that you've been ill. You can do this by filling in a form yourself when you return to work. This is called self-certification. Visit the following link for information and the form for self-certification

More than 7 days off sick

If you're off work sick for more than 7 days, your employer will usually ask for a fit / sick note (or Statement of Fitness for Work) from a GP or hospital doctor. Fit / sick notes are sometimes referred to as medical statements or a doctor's note.

For more information please visit;

When do I need a fit /sick note? (NHS information)

The fit / sick note: guidance for patients and employees (GOV.uk)

Your Details

Title

First Names

Surname

Date of Birth

NHS Number (if known)

Home Address

Postcode

Telephone

Mobile

E-mail Address

Details

Have you had a fit / sick note for this condition before?

If no, please contact the surgery for an appointment

If yes, please provide details of the previous note and why you require an additional note

Start date for the note

End date for the note

Are you fit for work as long as there are alterations to your workplace (e.g. adaptations to the workplace or working hours)?

If yes, please provide details

Privacy Protection

Information submitted through secure forms is used only for the purposes of processing your request. We may be in touch with you in relation to the information submitted.

All Information submitted through secure forms is secured with a private key and is accessed over a secure connection by nominated staff. We have a strict confidentiality policy.

This information is not shared with any third party organisations.

This information is retained for up to 28 days.

I consent to my information being used for the purposes described above and wish to submit this online form to The Old Fire Station Surgery • 68a Portsmouth Road, Woolston, Southampton, SO19 9AN.

Learn more about our Privacy Policy and Terms of Use. Should you have any concerns about sending your personal details using the web, please use one of the alternative methods offered by our organisation.