Sick / Fit Note Request Is this your first sick / fit note for this illness? Yes No, I have already had a sick / fit note for this illness First Sick / Fit NoteHow long have you been ill (including holidays and weekends)? 7 days or less More than 7 days If you have been sick for more than four days in a row, but less than seven, you can self–certify your illness using a SC2 form available online from HMRC. Many employers have their own self-certification forms. You do not need to see a Doctor.Are you self-isolating because you, or someone you live with, has symptoms of coronavirus? Yes No Requesting an additional Sick / Fit Note If you have already had a Note for this illness your Doctor may not need to see you to issue an additional Note. Please complete this form. We will contact you to let you know when your Note is ready or we may contact you for more information.Isolation Note from 111 Please check the NHS guidance on self-isolating here www.nhs.uk/conditions/coronavirus-covid-19/self-isolation-advice/. You can get an isolation note from 111 online to give to your employer. You do not need a sick note from the surgery.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. The surgery may call you for more information. If you have already been seen by your Doctor about this illness your certificate will be sent to you within a week. Please complete the form below.Your detailsName First Last Email Enter Email Confirm Email Date of Birth Day Month Year Contact NumberHow would you prefer to receive the note? Text Message Email Your IllnessStart date for fit note Day Month Year End date for fit note Day Month Year What is the reason you cannot work?Describe your illness and why you need a Sick / Fit Note.Privacy PolicyThis 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. 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.