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  • 028 91247367
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Bloomfield Surgery Providing NHS services
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Home > Continuation Sickline Request Form

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

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.

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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Bloomfield Surgery

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

  • 028 91247367
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Local Services
Private
Dentist
Hearing Aids
& Services
Family Law
Financial
Planning