Sick/Fit Note - Abington Medical Centre

Doctor’s Sick/Fit Note for more than 7 days

If you have been ill for more than 7 days you will need a doctor’s certificate. These certificates are called ‘Fitness To Work’ Certificates. If you have been ill for 6 days or less, you will need to self-certificate. WE CANNOT PRE-DATE ANY SICK/FIT NOTES

Your Details

Full Name *

Date of Birth *

Phone Number

Email Address *

Sick/Fit Note

Date that you would like the Sick/Fit note to start *

Which date would you like the Sick/fit note to end? *

Which diagnosis would YOU like on the SICK / FIT NOTE? *

If you are able to work, what restrictions do we need to consider? (e.g. amended hours, avoid heavy lifting etc)

Disclaimer

This form collects your name, date of birth, email, other personal information and medical details. This is to confirm you are registered with the practice, to allow the practice team to contact you and also to update your medical records held by the practice and our partners in the NHS. I am aware that the Sick/Fit Note can take up 2 working days to process.

I consent to the practice collecting and storing my data from this form *

I consent

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Page last reviewed: 14 October 2020
Page created: 01 October 2020

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Doctor’s Sick/Fit Note for more than 7 days

Doctor’s Sick/Fit Note for more than 7 days

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