Med3(Sick Line) Request Form

Use this form to request a Med3 document from your doctor. Med3, also known as a Sick Line/Fit Note, provides evidence of your illness or injury and advises whether you are fit for work.

Please allow up to 4 working days for us to handle Med3 fit note requests. We aim to process them as promptly as possible, but want to provide time for your GP to thoroughly review your case. Please note you may receive a call from your doctor to discuss details that could help assess your fitness and work capacity before issuing a note.

Please note that GP surgeries are unable to provide fit notes in advance of the sickness period. Fit notes are intended to reflect your current state of health at the time of issue. If you're requesting an extension, your request will not be dealt with until your current Med3 has run out. Your GP can backdate a fit note to the appropriate start date as supported by your condition and medical history if necessary (any request to backdate a note will be considered on a case-by-case basis).

Last Updated: 06/02/2024

Personal Details

Surname *

First name(s) *

Date of Birth *

Home address *

Mobile *

Email *

Details of your illness/injury *

Is this your first Med3 for this particular problem, or are you requesting an extension to existing Med3? *

New Med3

Extension of existing Med3

If you're requesting an extension, please advise when does your current Med3 run out

How long to do you require the sick line for? *

Consent

By completing and submitting this form to request a fit note, you give your consent for the surgery to contact you if further information is needed to process your request. This may be via phone call, email, or text message. We treat your personal information confidentially and will only use it regarding this fit note request. Please ensure the contact details you provide are current so we can reach you.

Signature

Signature (If unable to put electronic signature in, please type name) *

Date *

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Med3(Sick Line) Request Form

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