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

Contact Telephone NumberThe Doctor may wish to contact you for further information.

Name

Date of Birth

Address

Sickline Request Details

Date FromDate your last line ran out.

Length of time requestedPLease specify in weeks not dates eg. 1 week, 2 weeks

Diagnosis causing absence from work.

Date of last appointment with Doctor

Return to Work

Date you need sickline to finishThis is for a final line which will allow you to return to work

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 Bloomfield Surgery • 95 Bloomfield Road, Bangor, Co. Down, BT20 4XA.

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.

Key Information

Continuation Sickline Request Form

Privacy Protection