Free Doctors Excuse Note PDF Form
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Preview - Doctors Excuse Note Form
DOCTOR’S EXCUSE NOTE
Institution: ____________________________________________
Dr. ___________________________________________________
Address: ______________________________________________
Phone: ________________________________________________
Email: ________________________________________________
Date of examination: _______________, 20_____
Return appointment: _______________, 20_____
That is to certify that patient __________________________________ was under my care at my
office on _______________, 20_____. Please excuse this absence.
Health issue description:
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
EXAMINATION RESULT
□Full Duty: may return to work\school without any restrictions or limitations.
□Light Duty: may return to work\school with restrictions and\or limitations (described below). Restrictions duration: _____________; Limitations duration: _____________;
□Off Work: patient cannot return to work\school and is not able to perform their duties until _______________, 20_____ or until next evaluation.
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RESTRICTIONS (if applicable)
□ |
No bending |
□ |
□ |
No twisting |
□ |
No lifting more than ____ lbs.
No climbing
□Other:
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
LIMITATIONS (if applicable)
□Working\Studying hours per day allowed: ____ hours.
□Must take at least ____ breaks during the working\studying day.
□Minimum break duration: ____ minutes.
□Must wear a brace
□Other:
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
Additional Doctor’s Comments:
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________
(doctor's signature)
2
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Similar forms
- Medical Leave Request Form: This document serves as a formal request for time off due to medical reasons. Like the Doctor's Excuse Note, it requires validation from a healthcare provider to ensure that the employee's absence is justified.
- Return to Work Authorization: After an illness or injury, this form confirms that an employee is fit to return to their job. Similar to the Doctor's Excuse Note, it often needs to be signed by a medical professional to verify the employee's health status.
- Patient Health Record: This document contains a summary of a patient's medical history and treatment. While it is more comprehensive than a Doctor's Excuse Note, both documents share the purpose of providing essential health information relevant to employment.
- Short-Term Disability Claim Form: Employees use this form to apply for benefits when they cannot work due to medical reasons. It requires documentation from a healthcare provider, much like the Doctor's Excuse Note, to substantiate the claim.