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.

Fitter Futures (Weight management & Lifestyle advice)

Help Stopping Smoking

Help Reducing Alcohol Consumption

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 331401. 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.

Email Address:

Please select the option which applies to you

I confirm that I already have a sick note and wish to only extend it

I do not yet have a sick note but I have already been reviewed by a medical professional

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

Which doctor last reviewed you?

If Dr not on this list please state below:

Current sick note end date (If applicable):

When was your first sick day in this episode of illness?If this date is not 7 days prior to today's date your sick note will be rejected as self-certification is now 7 days long. To find out more about the recent changes visit: https://www.gov.uk/taking-sick-leave

Please enter the date you would like the sick note to start fromPLEASE NOTE THAT WE CANNOT USE A DATE IN THE FUTURE. Either today or a date in the past.

Please enter how long you would like the sick note for

Reason for sickness?Please define the reason you are unable to work e.g. Recent heart attack

Please tell us how your condition prevents you from working?It is important you communicate with your employer to explore alterations in your work to help facilitate a return

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

How would you like to receive your sick note if approved?Please ensure you have given the relevant details e.g. mobile number or email at the top of the 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 Clarendon Lodge Medical Practice • Clarendon Lodge, 16 Clarendon Street, Leamington Spa, Warwickshire, CV32 5SS.

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.