04. Fit/Sick Note

Fit/Sick Note Request
This form is for fit/sick notes only. This form cannot be used to request appointments. If you have a health issue which you'd like to discuss please use the appropriate request form. In an emergency call 999.
HIDDEN SECTION

Patient will not see this area of the form
FIRST
REPEAT
First or Repeat?
email use
Registered with York Medical Group?*
Only patients registered with York Medical Group can request Fit Notes via this form.
NHS Number*
Name*

First NameLast Name
Sex at Birth*
Gender Identity*
Gender Code
Gender Codes
Date of Birth*

DayMonthYear
Date

Request Details
Name of clinician who issued your last fit note?*
Start date of LAST fit note*

DayMonthYear
End date of LAST fit note*

DayMonthYear
Requested start date of THIS fit note*

DayMonthYear
Requested end date of THIS fit note*

DayMonthYear
Please describe the symptoms causing the request for a fit note*
Do you want a note to work with adaptions or phased return?*

YesNo
E.g. some people want a fit note with light duties, reduced hours, no shift work etc
Please provide full details of your adaptions or phased return*

Confirmation
How would you like to receive your fit note?*

SMS Text MessageEmailPick up in person
Your mobile number*
This should be the number on your medical record
Your Email Address*
This will be saved to your patient record
Please select which site you would like to collect from*
You cannot currently collect from closed sites
Are you currently suicidal?*

NoYes
Help is available. Speak with someone today. Call the Samaritans on: 116 123, or text SHOUT to 85258.
Please note we aim to deal with requests within 5 working days
Should be Empty:

Fit/Sick Note Request