Fit Note Request Form

Requests for fit notes will take 3 working days to process before they will be ready for collection. Please complete this request form below and submit. If there is any further action required from you then we will contact you.

A fit note will not be issued for an absence of less than 7 continuous days. If you have not been absent from work for more than 7 days please contact your employer for advice on self-certification.

Today's Date

Full Name

Date of Birth

Home Address

Post Code

Contact Telephone Number

Email Address

Usual GP

Reason for Absence

Is this the first fit note for this period of absence?

If yes, have you self-certified your absence for 7 working days?

Is this a continuation certificate?

If yes, what date is the certificate due?

If no, what is the start date for the certificate?

If continuation line how long are you anticipating off work?

If you are returning to work what date is your return?

If you are returning to work are you returning as part of a phased return?

This form collects your name, date of birth, email and other personal information along with certain medical details. This is to confirm that you are a registered patient with Cowdenbeath Medical Practice to allow the Practice team to contact you to discuss the management of your medical care and also to update the records that we hold. For further information on how we protect and manage your submitted data please read our privacy policy.

I consent to the Practice collecting and storing my data from this 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 Cowdenbeath Medical Practice • 173 Stenhouse Street, Cowdenbeath, Fife, KY4 9DH.

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.

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