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.
You must self certify for the first 7 days of sickness using the link below:

https://www.gov.uk/guidance/ask-your-employer-for-statutory-sick-pay

York Medical Group will not supply a sick note for your first 7 days of sickness.
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