Medical Certificate Form
Medical Certificate Form
Please complete this form to certify the medical status and treatment details of the patient.
Patient Information
Name
Date of Birth
Phone Number
Please provide your email address.
Medical Examination Details
Date of Examination
Diagnosis
Treatment Provided
Prescribed Medications (if any)
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Medication Name |
Dosage |
Frequency |
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Fitness for Work/School
Is the patient fit for work/school?
If no, estimated recovery period
Recommended Rest Period (if applicable)
Activity Restrictions (if any)
Certifying Physician Information
Physician's Name
Medical License Number:
Phone Number
Clinic Address
Physician's Signature
Name:
Date:
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