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

PLEASE NOTE YOU MUST SELF CERTIFY FOR THE FIRST 7 DAYS OF YOUR ILLNESS. A SICKNOTE WILL NOT BE ISSUED DURING THIS TIME.

DO NOT COMPLETE THIS FORM UNTIL YOU HAVE CONSULTED WITH A HEALTHCARE PROFESSIONAL AS WE WILL BE UNABLE TO ISSUE A SICKNOTE.

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 doctor may call you or arrange for an appointment. If you have already been seen by your Doctor about this illness your certificate will be sent to you within a week.

Your Details

Full Name *

Date of Birth *

Phone Number

Email Address *

Sick/Fit Note

FIRST DATE YOU WERE NOT AT WORK DUE TO THIS ILLNESS *

DATE YOU REQUIRE THE SICK NOTE TO START (date has to be after 7 days of self certification) *

DATE YOU REQUIRE THE SICK NOTE TO END *

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

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.

This form is protected by reCAPTCHA and the Google Privacy Policy and Terms of Service apply.

Page last reviewed: 08 July 2025
Page created: 06 August 2020

Cookies on the Birchgrove Surgery website

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

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

Further Information