Fit Notes/Sick Notes

Statement of Fitness for Work – ‘Fit Note’

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

If you need a regular sick note you can apply for these through our online Klinik service. Simply click on the following link Fit Notes – Wistaria and Milford Surgeries

Sick Note Request

Self-certification

If you are off work for 7 days or less, you DO NOT need to give your employer a fit note from a doctor.

When you return to work, your employer can ask you to confirm you’ve been off sick. You and your employer will need to agree on how you would do this.

Click here for more info about Self-certification

Are you registered with Wistaria & Milford surgery?

Only patients registered with Wistaria and Milford surgery can request a fit note with this form

Click here for information on how to Register

Are you requesting on behalf of someone else?

Myself

Someone else

What is your relationship with the patient?

Requester details

First Name

Last Name

Contact Number

Patient Details (details to go on fit note)

First Name

Last Name

Date of Birth

1st line of address

Request Criteria

Have you requested a fit note for this problem before?

Yes

Request Details

Name of doctor who issued last fit note

Start date of your LAST fit note

End date of your LAST fit note

Start date of fit note you’re requesting (must not be a future date)

End date of fit note you’re requesting

Please describe symptom causing the request for fit note

Do you want a note to work with adaptions or phased return?

Yes

Any return to work adaptions or altered hours will need to be agreed with your employer.

If they cannot accommodate your requirements, then they can treat this as a normal sick note.

Please provide details of your adaptions/phased return

How would you like to receive your fit note?

SMS text message

Pick up in person

Confirm your email

Please select which surgery you would like to collect from

Confirm your mobile number

We aim to deal with sick note requests within 3 working days

If you are human, leave this field blank.