Online FIT Note request - North Cardiff Medical Centre

Important Information

PLEASE NOTE - OUR CLINICIANS CANNOT ISSUE A SICK NOTE IF THEY HAVE NOT SPOKEN TO YOU REGARDING YOUR CONDITION. PLEASE CALL THE SURGERY TO MAKE AN APPOINTMENT IF YOU HAVE NOT DISCUSSED YOUR CONDITION PRIOR TO COMPLETING THIS FORM.

ANY FORMS COMPLETED WITHOUT PRIOR DISCUSSION WITH A CLINCIAN MAY BE REJECTED.

The clinicians are unable to issue sick/fit notes to start from a future date.

If a date in the future is required please submit this form on the the date you require the note from.

By clicking below you agree that your request is NOT for a future request. If a form is submitted to start from a future date it will be rejected and you will need to submit a new request on the date you wish the note to start from.

Sick/Fit Notes can only be issued from the date of form submission or to start from a date in the past. We CANNOT issue notes to start from a future date. We can only issue sick notes for conditions already discussed with a Clinician. We CANNOT issues notes for conditions not previously discussed. *

I agree that my request IS NOT for a sick/fit note due to start from a future date. I also agree that I have spoken to a clinician at North Cardiff Medical Centre regarding my condition prior to completing this form.

Name

Please supply your full name

New or Continuation

Please tell us the start date required for this Fitness to Work Certificate? *

Please tell us the end date required for this Fitness to Work Certificate *

How long do you expect to be ill for? *

Have you recently been discharged from hospital or had a clinical assessment resulting in your not being able to work? *

Yes No

If you answered yes to the question above please provide details below

Please tell us why you require a sick note *

What is your occupation? *

Have you seen or spoken to occupational health? *

Yes No

Would you be able to return to work if you had a Fitness to Work Certificate with any of:

Any Further Information

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.

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