Sick Note Request

Have you self-certified for the first 7 days? If not please go the GOV.uk website and complete an SC2 form.

For 'new' sicknotes you must make an appointment with the GP.

To request an additional sicknote to follow-on from a current note. Please complete the form below.

Sick Note Request

Full Name

Date of Birth

Contact telephone number

Contact email address

Additional Sick/Fit Note Request

First date you were not at work due to this illness?

Total number of days you were ill (or state ongoing)

Describe your illness and why you need a sick/fit note

Date note required from

Date note required to

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

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 Penn Surgery • 2a Coalway Road, Penn, Wolverhampton, WV3 7LR.

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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