Request for an extension to your sick note

If you have already had a sick note for this illness your GP may not need to see you to issue an additional sick note. Please complete this form.

Please note it is not possible to future date sick notes. Your sick note will be ready to collect the day after it is due to start.

If the GP requires additional information or to arrange an appointment to discuss your situation further, reception staff will contact you.

Extension to Sick Note Request

Full Name *

Date of Birth *

Phone Number (mobile number preferred) *

Do you consent to receiving text updates? This may include appointment reminders, updates about your health or service updates *

Yes No

Extension to Sick Note Request

WHAT DATE TO YOU NEED YOUR SICK NOTE TO START? *

PLEASE STATE HOW MANY DAYS/WEEKS YOU REQUIRE YOUR SICK NOTE FOR? *

DESCRIBE YOUR ILLNESS AND WHY YOU NEED A SICK NOTE *

This form collects your name, date of birth and 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.

The information you provide on this form will be sent to our practice and used only to deal with your request. Depending on the form, this may include your contact details, personal information and health information. The practice may add it to your medical record and, where needed for your care, share it with other NHS and care services. To find out how we protect and use your information, please read our privacy policy on our website.

I confirm the information I’ve given is correct and I understand how it will be used

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Page last reviewed: 11 November 2024
Page created: 15 October 2026

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Request for an extension to your sick note

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