Request for a sickness certificate

Examples, to extend an existing sickline or after speaking to a medical professional e.g A&E, Minor Injuries etc. By sending in this form you are agreeing to receive email and/or sms communications from us. We will only use this information to communicate with you about Penicuik Medical Practice and the service we provide.

Patient Details

Information on the patient

Name: *

Date of Birth: *

Telephone Number: *

Address: *

Email Address - Why do we want this – our preferred way to send Medical Certificates is digitally, this is quicker and is better for the environment

Reason for absence: *

When does your current sickline expire? *

Name of your usual GP: *

How many weeks are you requesting this sickline to cover *

Do you have a review appointment arranged? If yes, please give details on type of appointment and who with.

Please note

The doctor may not necessarily issue you with a sickness certificate following this request. You may need an appointment/telephone call before a certificate can be issued. Please leave 3 working days for GP assessment and completion of certificate.

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Page last reviewed: 03 August 2023
Page created: 01 July 2019

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Request for a sickness certificate

Request for a sickness certificate

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