Additional Sick Note Request Form - Old Kilpatrick Medical Practice

Fit Note

If you have been ill for more than 7 days you will need a doctor’s certificate. These certificates are called ‘Fitness To Work’ Certificates. Please provide as much information as possible in this form regarding the reason for your absence. The practice may contact you if we need further information.

Your Details

Full Name *

Date of Birth *

Phone Number

Email Address *

Fit Note

Date fit note to start or renew? *

Length of Fit Note requested? *

Please describe why you are unable to work at present. *

Please describe what steps you are taking to return to work (if applicable).

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.

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Page last reviewed: 02 April 2026
Page created: 03 May 2023

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