Fit / Sick Note Request

Please note that we require 5 working days notification for a sick note to be issued. We require mobile telephone number in order to send you the sick note electronically. All fit / sick notes are sent electronically.

Please note that you will not get confirmation after you have submitted the form. There is no need to submit the form multiple times. If the form failed you would be notified but otherwise be assured that we receive and action all forms submitted.

Thank you for your understanding and support

Phoenix Family Care Team

Full Name

Date of Birth

Full Address

Mobile Telephone NumberIt is essential for us to have mobile telephone number to be able to message you the sick note electronically

Reason for fit/sick note

Starting Date

Ending Date

Additional Comments

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 Phoenix Family Care (GP Surgery in Coventry) • 103 Leamington Road, Coventry, CV3 6GQ .

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.