Med3 (Statement of Fitness to Work) extension request

Please complete the form below to request an extension to an EXISTING sick line. This form is NOT TO BE USED FOR REQUESTING A SICK LINE FOR A NEW ILLNESS/REASON FOR ABSENCE.

Please complete all the required fields. The request will be put to the GP who issued the original sick line for them to consider an extension or another GP if they are absent.

If you do not hear from the practice, the sick line will be ready to collect after 5 working days. If the GP wishes to speak to you, the administration team will call you and arrange a telephone appointment with them. If you are consented to text messaging, we will text you to let you know your sick line is ready. We do not email or post sick lines to patients. They can be collected by a represenative with your permission.

PLEASE NOTE: SICK LINES CAN BE BACKDATED, SO THESE WILL NOT BE TREATED AS URGENT REQUESTS. YOUR EMPLOYER DOES NOT NEED A SICKLINE IN THEIR HAND THE DAY THE LAST ONE EXPIRES. WE CAN NOT PRINT SICK LINES IN ADVANCE OF THE EXPIRY DATE. THANK YOU

Last Updated: 23/07/2024

Patient Details

First Name *

Surname *

Date of Birth *

Telephone Number *

Address *

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.

MED3 Details

Please complete as fully as possible.

Name of GP who issued initial sick line? *

Is there any additional information that would assist the GP in making a decision? (I.e. recent appointments with consultants/physio?)

Expiry Date of Sick Line? *

Length of extension required? *

Do you need an appointment to discuss with the GP? *

Yes

I'm Not Sure

Do you have a plan to return to work? (Please give details)

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Med3 (Statement of Fitness to Work) extension request

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