Patient Request Form

Registered Patient Forms

If you are absent from work due to a condition which results in a hospital admission, a Fit Note may be issued by the hospital team to cover the period of time you were in the hospital and the expected rehabilitation period. If you require an extension of the Fit Note, please contact our admin team, ideally via PATCHS.

Please note that emergency or urgent appointments should not be used to request Fit notes.

Important Note to Remember

Illnesses of less than 7 days do not require certification
Minor ailments are not eligible for certification (e.g. prolonged flu/cold etc.)
Pregnancy and other conditions that are protected by the law do not necessarily require certification

Please Choose one of the following

Fit Note Request

Private Letter Request

Name

First name

Last name

Date of Birth

Phone Number

Email Address

Fit Note Request Form

Please complete the below form ensuring all boxes are completed

Please Note: Patients must have self certified for 7 days before requesting a Fit Note certificate from a GP

Request Start Date of Fit Note

Request End Date of Fit Note

Reason for Fit Note Request

Please Confirm

Please tick to confirm the patient has self certified for 7 days prior to this request being made

Please tick to confirm the patient’s contact number is correct and up to date

Private Letter Request

The practice may write a private report or letter in certain eligible circumstances. Please fill in the form below clearly stating your the reasons for your request. You may also upload any blank or pre-filled form that you wish the clinician to review.

Name

First Name

Last Name

Date of Birth

Contact Number

Email Address

Please write a detailed description of the type of letter required

File Upload

Maximum file size: 10MB

If you are human, leave this field blank.

Fit Note Request Form

Private Letter Request

Brunel Medical Centre

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