Printable Health Note

Date: [Month Day, Year]

Patient's Name: [Patient's Name]

DoB: [Date of Birth]

To Whom It May Concern,

This is to certify that the above-named patient was evaluated at our facility on                                and is advised to refrain from work/school from                                to                                due to a medical condition.

Medical Recommendation (if applicable):

• May return to work/school with no restrictions

• May return to work/school with the following restrictions:                                                                                                                                                  

• Follow-up appointment required on:                              

If further information is needed, please contact our office.

Physician’s Name:                                                           
Medical Facility:                                                              
Phone Number: