Fit Notes (Sick Line) | Gillbrae Medical Practice

Self certification without contact with the surgery for absence of less than 7 days : use form SC2

The form below should only be used if you have already spoken to a clinician and a fit note has been agreed, or if you have attended hospital and need a fit note in relationship to a specific hospital attendance.

Requests will be reviewed and duration is at the discretion of the clinician. If approved, your fit note will be sent to the email address we have associated with your medical record.

You will be contacted if further information is needed, or an appointment is required.

Fit notes can be backdated, but we cannot start them from a date in the future.

Name

Date of Birth

Email fit note

Pick up from desk

Email address

Occupation

Is this request:

Following consultation with your GP or nurse

Following hospital attendance

Clinician consulted

Date of last hospital appointment

Are you requesting:

to be signed off work?

to return to work (with conditions)?

(Most fit notes are "closed" and you do not need to be signed back to work)

Reason for fit note

Date fit note required from

Duration of fit note/until date

Return to work requirements

(Should be discussed with employer for feasibility)

Phased return to work

Altered hours

Amended duties

Work place adaptations

Additional information

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