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.



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.



Hospital discharge

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



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.

X/Twitter

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