Fitness for Work

How to request a Fitness for Work Form

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Evidence that you are sick

If you are sick for more than seven days, your employer can ask you to give them some form of medical evidence to support payment of SSP (statutory sick pay).

It is up to your employer to decide whether you are incapable of work. A medical certificate, now called a ‘Statement of Fitness for Work’ (see below) from your doctor is strong evidence that you are sick and would normally be accepted, unless there is evidence to prove otherwise. Should you require a ‘Statement of Fitness for Work’ please mention this when you call us. We will call you back to discuss your ongoing need before issuing one.

You could also provide evidence from someone who is not a medical practitioner, e.g. a dentist. Your employer will decide whether or not this evidence is acceptable. If your employer has any doubts, they may still ask for a medical certificate from your GP.

Statement of Fitness for Work – ’Fit Note’

The ‘fit note’ was introduced on 6 April 2010. With your employer’s support, the note will help you return to work sooner by providing more information about the effects of your illness or injury.

You do not require a separate medical note to confirm you are fit to return to work. For more information see the DirectGov website (where this information was sourced)

Under the Data Protection Act you have the right to get a copy or have sight of the information that is held about you. This is known as a subject access request. Please check the charge for this with the receptionist.

NHS Digital Data Provision Notice for Individual GP Level Data – Information for Patients

Your Personal Data Information Choices

Fitness for Work Form

Required fields are marked with an asterisk (*).

This form is for Continuation Sickness Forms Only

You do not require a doctor’s sickness certificate for any illness lasting seven days or less. Your employer may however require you to complete a self-certification form (SC2) which is available from your employer or on the HMRC website

Today’s Date

First Name*

Surname*

Date of Birth*

Telephone number*

Patient’s Email address*

House Name/Number*

Street*

Town*

Postcode*

End Date*

Please provide the end date on your current sick note

Start Date*

Please provide the start date you require on your new Sick note?

Duration*

How long do you require this new sick note for? i.e. 7 days or 28 days

Reason*

Please give the reason for absence to be documented on sick note?

How would you like to receive your sick note?*

Post to registered address

Collection from reception

Receive via AccuRX

If collection please specify site

*Please make sure all Mandatory fields have been completed

Privacy Consent

This form collects personal and medical information about you. We use this information to allow the practice team to contact you. 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

Are you human?*

This field should be left blank

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Please note this form is not to be used for the following purposes:

Medical matters, Prescription requests, Patient Access requests, Appointment requests or Complaints. Medical matters cannot be dealt with via this form. If you have a query regarding a medical matter please telephone reception to make an appointment to see the appropriate person.

Other forms available

Register as Patient

Please visit our Patient Registration page and fill in the health questionnaire to register as a patient at Teldoc.

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Please visit our Change of Name Form to update your details

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