Simple Doctor’s Note for Work

To Whom It May Concern,

This is to certify that                                                          (Patient Name) was evaluated by me on         /         /         and, due to medical reasons, is advised to refrain from work from         /         /         to         /         /        . The patient is expected to return to work on         /         /         , with or without restrictions as necessary.

If further information is required, please contact my office.

Sincerely,

Physician's Name:                                                     
Medical Facility:                                                         
Contact Information:                                                  

Date:         /         /