Self-Certification of sickness, New sick note requests & request an additional Sick / Fit Note

1. Self-Certification of sickness

If you have been ill for 7 days or less, you don’t need to see a doctor. You can complete a Self-Certification form yourself. Click here for more details

2. New Sick Note Request (If you have been ill for more than 7 days)

If you have been ill for more than 7 days you will need a doctor’s certificate.

We can only issue a new certificate once you have spoken to a clinician. Please contact the surgery to request a New Certificate.

Call the surgery - 01495 772239

3. If you need an extension to a sick note

If you have already had a Sick Note (Fit Note) for this illness, your Doctor may not need to see you to issue an additional Sick Note.

Please complete this form. We will contact you to let you know when you can collect your Sick/Fit Note or we may contact you to arrange an appointment.

Failure to complete all form details will result in your request being rejected by the surgery. It is important that you provide as much detail as possible to enable the GP to assess your request for a fit note.

Full Name

Todays date

Date of Birth

Mobile Number/Contact Number

Email Address

ADDITIONAL SICK/FIT NOT REQUEST

What is your Job?

What is still preventing you from working?

Have your sought any help to return back to work?

FIRST DATE YOU WERE NOT WORK DUE TO THIS ILLNESS (DD/MM/YYYY)

TOTAL NUMBER OF DAYS YOU WERE ILL?

DESCRIBE YOUR ILLNESS AND WHY YOU NEED A SICK / FIT NOTE

PLEASE STATE HOW MANY DAYS/WEEKS YOU REQUIRE YOUR SICK NOTE FOR?

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. Please read our Privacy Policy to discover how we protect and manage your submitted data.

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

Yes

Abersychan Group Practice