Requesting an additional Sick / Fit Note - Ashton View Medical Centre

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.

Requesting an additional Sick / Fit Note

Full Name *

Date of Birth *

Phone Number *

Email Address *

SICK/FIT NOTE

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

TOTAL NUMBER OF DAYS YOU WERE ILL OR IS STILL ONGOING *

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.

If you are human, leave this field blank.