Doctor’s Fitness To work Certificate – Ongoing Treatment / Continuation

If you have already had a Fitness to Work Certificate (Sick Note/Fit Note) for this illness, or you are currently being treated for this issue by your GP, then they may not need to see you to issue an additional Certificate. So we ask you to send in this form instead.

Please complete this form. 

We will contact you to let you know when you can collect your Certificate or we may contact you to arrange an appointment.

YOU MUST BE A REGISTERED PATIENT WITH THE PRACTICE TO USE THIS FORM

Doctor’s Fitness To work Certificate – Ongoing Treatment / Continuation

If you are human, leave this field blank.

Full Name: *

Date of Birth: *

Please use this date format: DD/MM/YYYY.

Mobile Phone Number (preferable):

Home Phone Number:

Email Address: *

If you don't provide an email address we won't be able to respond to you by email

First date you were not at work due to this illness:

Please use this date format: DD/MM/YYYY.

Describe your illness and why you need a Sick Note/Fit Note:

*

I confirm I am a registered patient at Montgomery House Surgery