Requesting continuation of Sick Note (MED3)

You can use this form if you currently have sick note (MED3) and feel you are not ready to return to work yet. If you are requesting a new sick note for a reason that you have not discussed with a Doctor, you will need to arrange a telephone call with a Doctor first.

Last Updated: 24/06/2020

Sick/Fit Note Request

Full Name *

Date of Birth *

Phone Number *

Email Address *

Additional Sick/Fit Not Request

When did your previous Sick Note (MED3) run out? *

Please describe your illness/reason for sick note (MED3) *

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.

Requesting continuation of Sick Note (MED3)

Further Information