Sick / fit note extension

Use this form to help us direct you to the best place for requesting a sick note.

You may be asked to provide the number of days you have been sick for.

Calculate sick days

Here is how to calculate your total number of sick days.

Is this your first request for a sick / fit note for this illness?

Yes, this is my first request

No, I have already had a sick / fit note for this illness

First name

Last name

Phone number

Door number / property name

Post code

Are you still ill with this illness?

Yes, I am still ill

No, I am no longer ill

Number of days you have been sick

Clinician you have seen

How long are you requesting this sick / fit note for?

If you would like a copy of your submission, please tick the box below and supply an email address.

Send me an email receipt with the details from this form

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