Request a Medical Certificate (Sickline)

Please read the following information carefully before submitting this form. A GP can only complete a medical certificate if they have consulted with you about the problem, or they are in receipt of your hospital attendance. The Medical Certificate can only be completed ON THE DAY IT IS DUE, or backdated accordingly. It cannot be completed in advance. Please submit you request for a medical certificate in advance to allow the Practice time to process your request.

Your completed medical certificate will be emailed to you within 48 hours of its due date.

Please use this submission form for the following requests:

* Continuation sickline

* A new sickline following a hospital admission/fracture (and you have completed a self certification covering your first 7 days of sickness)

If you require a first sickline, and have not spoken to the GP regarding the problem, please contact the Practice by telephone.

Last Updated: 23/02/2024

Your Details

Full Name *

Date of Birth *

Phone Number

Email Address *

Sick/Fit Note

Is this a continuation certificate? *

Yes - proceed to question 4

No, this is my first request from the GP - proceed to question 2

If this is your first request, please confirm:

If you have attended hospital, please provide dates and hospital name

DATE MEDICAL CERTIFICATE IS DUE *

HOW LONG DO YOU REQUIRE? *

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

Please specify if you require: *

A phased return, please specify below

Altered hours, please specify below

Amended Duties, please specify

Workplace adaptations, please specify

None, I am not fit for work in any capacity

Please specify amendments here:

This form collects your personal information and medical details. This is to confirm you allow the practice team to contact you and also to update your medical records held by the practice. *

I consent to the practice collecting and storing my data from this form.

Please tick to confirm that you understand that the Practice will email you a copy of your medical certificate within 48 hours of the date it is due, and it cannot be issued in advance of this date.

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Request a Medical Certificate (Sickline)

Further Information