Request a sick note

Use this form if you need to request a fit note or sick note from Daisy Villa Medical Practice.

Do not use this form for urgent medical help. If you are very unwell or your symptoms are worsening, contact the practice, NHS 24 on 111, or 999 in an emergency.

From July 2022, fit notes can be certified and issued by nurses, occupational therapists, pharmacists and physiotherapists, as well as doctors, and no longer require to be signed.

Sick notes can only be issued when they are due. Although they can be back-dated, they cannot be future-dated. Please do not request an emergency consultation for a Sick/Fit Note.

Sickness Certificates
You do not require a doctor’s sickness certificate for any illness lasting seven days or less. Your employer may however require you to complete a self-certification form (SC2) which is available from your employer or on the HMRC website.

Statement of Fitness for Work – ’Fit Note’
Sick notes should only be issued for people that are incapable of all work. If you feel that you are capable of some work but not your usual duties, you could consider this with your employer and they may be able to accommodate changes to your work or role to keep you working. When you consult us about a medical problem that affects your fitness to work we may consider this option with you. We can request your employer make some adjustments in a ‘May be fit for work’ note. This may allow you to get back to work sooner and support your recovery. If your employer cannot support the changes we request to keep you at work, they can just treat the note as a ‘sick note’ to allow you to be off work and support the payment of statutory sick pay.

For more information see the DirectGov website

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Self-certification

You usually do not need a doctor’s sick note for the first seven days of illness. Your employer may ask you to complete a self-certification form.

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Hospital discharge

If you have been discharged from hospital, the hospital team should issue any fit note needed for that period of recovery.

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Back-dated notes

Sick notes can only be issued when clinically appropriate. They cannot be future-dated.

Sick note request form

Complete the questions below. Include the dates you need covered and a short explanation of why you are not fit for work.

This field is for validation purposes and should be left unchanged.

We're sorry to hear you've been feeling ill. Is this your first sick / fit note for this illness?(Required)

Yes

No, I have already had a sick / fit note for this illness.

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 the following information and we will contact you to let you know when your Note is ready or if we need more information. If you do not hear from us, please collect your Sick Note after 24 hrs.

What's your name?(Required)

First Last

What's your date of birth?(Required)

What's your phone number?(Required)

What's your email?(Required)

When does your current sick note end?(Required)

How much longer do you need from that date?(Required)

e.g. 4 weeks

Please briefly tell us why you are currently unable to work(Required)

This field is hidden when viewing the form

How long have you been ill?

How long have you been ill?(Required)

7 days or less

More than 7 days

(including holidays and weekends)

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

These certificates are called ‘Fitness To Work’ Certificates. If you have been ill for 7 days or less, you may not need a doctor’s certificate. If you would still like to complete the form then you may do so. Please complete the following form. The surgery may call you for more information if required. If you do not hear from us, please collect your Sick Note after 24 hrs. If you have already been seen by your Doctor about this illness, your certificate will be sent to you.

What's your name?(Required)

First Last

What's your date of birth?(Required)

What's your phone number?(Required)

What's your email?(Required)

Please briefly tell us why you are currently unable to work(Required)

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. Please complete the following form. The surgery may call you for more information if required. If you do not hear from us, please collect your Sick Note after 24 hrs. If you have already been seen by your Doctor about this illness, your certificate will be sent to you.

What's your name?(Required)

First Last

What's your date of birth?(Required)

What's your phone number?(Required)

What's your email?(Required)

Please briefly tell us why you are currently unable to work(Required)

Thank you for completing the form. After you click submit this will be sent to the surgery. If any further information is required we will let you know. If you do not hear from us, please collect your Sick Note after 24 hrs.

Need help?

Daisy Villa Medical Practice
01856 831 206

Out of hours
NHS 24: 111

Emergency
Call 999