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The Orchard Medical Centre NHS GP Surgery in Salford

Sick (fit) note request

Sick / Fit Note Request

Required fields are labelled

What is your name? Required

First name

Last name

What is your date of birth? Required

For example, 31 3 1980

Day

Month

Year

What is your sex? Required

As recorded on your medical record

Male

Female

Other

What is your postcode? Required

The one used to register with your GP

What is your phone number? Required

What is your email address? Required

Anyone else with access to your email account may see responses sent to you

First date you were not at work due to this illness: Required

Please use this date format: DD/MM/YYYY.

Total number of days you were ill or state ongoing: Required

Describe your illness and why you need a sick note: Required

What is your current employment status? Required

Employed

Unemployed

Retired

In full-time education

What is your current occupation? Required

Are there any restrictions from stopping you returning to work? Required

Yes

Are there any restrictions from stopping you returning to education? Required

Yes

How long have you been unemployed for? Required

0-3 months

3-6 months

3-12 months

12-18 months

18-24 months

Over 24 months

What have you tried to do to get back into work? Required

How would you like to receive your sick note? Required

By email

Pick up at the practice

If you are human, leave this field blank.

10 Leigh Road
Boothstown
Worsley
Manchester
M28 1LZ

Get directions

0161 702 8579

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