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.

Is this request:
Are you requesting:
(Most fit notes are "closed" and you do not need to be signed back to work)
Return to work requirements

(Should be discussed with employer for feasibility)

This question is for testing whether or not you are a human visitor and to prevent automated spam submissions.