Sick note request NQHC

For your first 7 days of sickness you do not need to contact a GP for a sick note.

If you have been ill for more than 7 days you will need a doctor’s certificate.

If you have already been seen by your Doctor about this illness your certificate will be sent to you within a week.

You must have seen/spoken to a doctor regarding the reason you are requesting to be signed off for.

If you have not seen/spoken to the GP, please do not complete this sick note request, instead complete an appointment request via Klinik.

Last Updated: 24/07/2023

Your Details

Full Name *

Date of Birth *

Phone Number *

Email Address *

Sick/Fit Note

HAVE YOU SELF CERTIFIED FOR 7 DAYS? *

Yes No

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.

PLEASE ENTER THE DATE YOU WOULD LIKE YOUR SICK NOTE TO START FROM *

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

PLEASE SELECT THE DURATION NEEDED FOR YOUR SICK NOTE *

ONE WEEK

TWO WEEKS

ONE MONTH

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Sick note request NQHC

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