Sick Note Extension Request

Your details

Please use this form only for extension of current sick notes. Initial sick notes will need to be discussed with the GP through a consultation.

A charge of €20 applies for extension of private sick notes. Private sick notes/ notes for employers will need to be collected at the reception.

Social Welfare Certs will be emailed directly to the Department of Employment Affairs and Social Protection (DEASP). You must confirm the dates through “My Welfare” for payment processing found here. A maximum of 4 weeks will be issued at a time for long term Social Welfare Certs.

First Name *

Surame *

DOB (DD/MM/YY) *

PPS

Address

Eircode *

Phone Number*

Email Address*

Medical reason stated on the previous sick note?

Reason for sick note extension?

How long do you anticipate you will need to extend your sick note by?

How will you benefit from extension of your sick note?

What are you doing to facilitate the end of your sick note requirements?

Please confirm you no longer have acute medical needs requiring medical attention? ( If you do please book a review consultation)

By submitting this form you consent to our privacy policy here.

ALERT

This form is for extension of current sick notes only.
If you have a NEW Medical Problem requiring a Sick Note you will need to have a consultation with the GP.

Please call the reception to arrange this.

Sick Note Extension Request

Your details

ALERT

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