Sick Note Request Form

Please use this form if you are requesting for an extension to a sick note you currently have.

If you are requesting for a sick note for the first time, you will need to book an appointment to discuss this with a clinican. Please call to make an appointment at 8am Monday to Friday on 0208 888 6662.

If you have been off sick for less then 7 days, we are unable to provide you a sick note and you must contact your employer about SSP. Please visit the link here for more information. SSP Info

ALL REQUESTS WILL TAKE 48 WORKING HOURS OR TWO WORKING DAYS

Your Details

Full Name *

Date of Birth *

Mobile Phone Number *

Email Address *

Sick Note Details

Date for Sick Note to Begin *

Date for Sick Note to Finish *

Please state the reason why you need a sick note *

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.

The information you provide on this form will be sent to our practice and used only to deal with your request. Depending on the form, this may include your contact details, personal information and health information. The practice may add it to your medical record and, where needed for your care, share it with other NHS and care services. To find out how we protect and use your information, please read our privacy policy on our website.

I confirm the information I’ve given is correct and I understand how it will be used

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Page last reviewed: 22 February 2024
Page created: 05 November 2026

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Sick Note Request Form

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