Request an additional Sick / Fit Note - Nantgarw Road 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 only AFTER YOUR LAST FIT NOTE EXPIRES.

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.

We may send your fit note by SECURE email/SMS link if we have your details (this will be a unsigned 'e-fit note' and is acceptable for the DWP under new rules) . Please ensure we have your current details.

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