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Continuation Sickline Request Form

REQUEST FOR A CONTINUATION SICKLINE OR SIGNING OFF LINE

PLEASE NOTE THIS FORM CAN ONLY BE USED FOR ONGOING CONDITIONS, FOR A FIRST SICKLINE PLEASE MAKE AN APPOINTMENT WITH THE DOCTOR.

Your Contact Details
The Doctor may wish to contact you for further information.
Sickline Request Details
Date your last line ran out.
PLease specify in weeks not dates eg. 1 week, 2 weeks
Return to Work
This is for a final line which will allow you to return to work

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This information is not shared with any third party organisations.

This information is retained for up to 28 days.

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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