Sick Note Extension - South Queensferry Medical Practice

Sick Note Extension Form

If you have already had a Sick Note (Fit Note) for this illness your Doctor may not need to see you to issue an additional Sick Note. Please complete this form. We will contact you to let you know when you can collect your Sick/Fit Note or we may contact you to arrange an appointment.

Your Details

Full Name *

Date of Birth *

Phone Number *

Occupation *

Email Address *

Sick/Fit Note Extension Request

Reason for being off work *

Date your last sick note ended *

When do you hope to return to work? *

Please give us a bit more information if you feel it may help. *

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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Page last reviewed: 27 May 2026
Page created: 27 May 2026

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Sick Note Extension Form

Sick Note Extension Form

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