Reception: Requesting a Sick Note (MED3)

If you have already had a Sick Note (Fit Note) for this illness or you have already been reviewed by one of our team regarding the relevant illness your doctor may not need to see you to issue an additional Sick Note.

Please note that you may be contacted by our GP to discuss the request. Otherwise, if your request is approved we will send it securely to your mobile phone. We aim to complete the whole process within 2 working days.

Please do not write any clinical queries on this form. Any clinical queries or request for appointments via this form will be discarded. To make an appointment either book online via the NHS app/Patient access or by calling reception 01926 316711. We will start to process your form by the next working day but it will take up to 2 working days to complete. Please DO NOT call before 2 working days as you will not receive a status update from reception or the administrative team. If you are NOT a registered patient then your form will be discarded. This service is only for patients registered at the surgery aged 16 and over; and for parents or legal guardians of children. Forms must be completed in the UK due to GDPR regulations.

Reception: Requesting a Sick Note (MED3)

Full Name:

Date of Birth (DD/MM/YYYY):

Contact Number (Preferably Mobile):If your request is approved you will receive a text to confirm it is ready to collect.

Do you need to extend a current sick note or get a new sick note?

Email Address:

Which doctor last reviewed you?

If Dr not on this list please state below:

Current sick note end date (If applicable; DD/MM/YYYY format)

Please enter the date you would like the sick note to start from (DD/MM/YYYY format)PLEASE NOTE THAT WE CANNOT USE A DATE IN THE FUTURE. Either today or a date in the past.

Please state the date your sickness began?Fit notes can only be issued after an initial week of self certification so do not request a note until you have done this

Please enter how long you would like the sick note for

Reason for sick note?Please define the reason you are unable to work

Sometimes temporary changes to your work can help in the recovery process. Please select the option below which you feel best applies*Please define what adaptations in the textbox below

Adaptations required:

What is your current smoking status?

How many units of alcohol do you drink per week?

What is your current weight?In kg or Stone

Please note: if you experience a fever (>37.8C) or a persistent cough (>4 hours) do not attend to collect your sick note. Instead self-isolate for 7 days & collect once this is over.

Privacy Protection

Information submitted through secure forms is used only for the purposes of processing your request. We may be in touch with you in relation to the information submitted.

All Information submitted through secure forms is secured with a private key and is accessed over a secure connection by nominated staff. We have a strict confidentiality policy.

This information is not shared with any third party organisations.

This information is retained for up to 28 days.

I consent to my information being used for the purposes described above and wish to submit this online form to Whitnash Medical Centre • 110 Coppice Road , Whitnash, Warwickshire, CV31 2LT.

Learn more about our Privacy Policy and Terms of Use. Should you have any concerns about sending your personal details using the web, please use one of the alternative methods offered by our organisation.

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Reception: Requesting a Sick Note (MED3)

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