WALK IN CLINIC
LOCATION_ADDRESS1 LOCATION_CITY, LOCATION_STATE LOCATION_ZIP
Ph: LOCATION_TEL_NUM1 Fax: LOCATION_FAX_NUM
Return to Work Note
| Employer Name: EMPLOYER_NAME | Date: DateStamp |
| Patient Name: FIRST_NAME LAST_NAME | D.O.B: DOB |
I have examined FIRST_NAME LAST_NAME and certify that HE_SHE_INITCAP is medically cleared to return to work on RETURN_TO_WORK_ON.
[ FULL DUTY ] Full Duty: The patient is cleared to perform all essential functions of their position without any restrictions.
[ MODIFIED DUTY ] Modified Duty: The patient is cleared to return with the following temporary restrictions from TEMP_RESTRICTIONS_FROM to TEMP_RESTRICTIONS_TO:
- Restriction 1: RESTRICTION_1
- Restriction 2: RESTRICTION_2
- Restriction 3: RESTRICTION_3
[ NO WORK ] No Work: The patient is not cleared to return to work at this time. Next evaluation: NEXT_EVAL_DATE.
Sincerely,
PROVIDER_NAME, PROVIDER_CREDENTIALS