Fitness for work / Sick note Request

The form below is only to be used for a repeat Fitness for Work / Sick note.

If you have not had a Fitness for Work / Sick note for this condition / issue, please contact the surgery to discuss why the note is required.

Your Details

Title

First Names

Surname

Date of BirthDD/MM/YYYY

NHS Number (if known)

Home Address

Postcode

Telephone

Mobile

E-mail Address

Details of the Fitness for work / Sick note Request

Have you had fit / sick note for this condition before?

If you have not had a Fitness for Work / Sick note for this condition / issue, please contact the surgery to discuss why the note is required

For repeat notes, please provide details of the previous note and why you require an additional note

Are you fit for work as long as there are alterations to your workplace (e.g. adaptations to the workplace or working hours)?

If yes, please provide details

Start date for the note

End date for the note

Privacy Protection

Information submitted through secure forms is used only for the purposes of processing your request. We may be in touch with you in relation to the information submitted.

All Information submitted through secure forms is secured with a private key and is accessed over a secure connection by nominated staff. We have a strict confidentiality policy.

This information is not shared with any third party organisations.

This information is retained for up to 28 days.

I consent to my information being used for the purposes described above and wish to submit this online form to Rough Hay Surgery (Training Practice) • 44b Rough Hay Road, Darlaston, West Midlands, WS10 8NQ.

Learn more about our Privacy Policy and Terms of Use. Should you have any concerns about sending your personal details using the web, please use one of the alternative methods offered by our organisation.

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