Return To Work/school Letter
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1DATE
MRN
RETURN TO WORK/SCHOOL
LETTER
NAME
To whom it may concern:
_______________________________________________________ was examined and
(Patient’s Name)
treated in our clinic on _______________________ I am recommending the
(Date)
the following based on the patient’s medical condition:
No work at all from _________________________ to _______________________
Unable to return to work until further evaluation
Light work only from ________________________ to _______________________
May return to work on ____________ with the following restrictions:
No lifting in excess of ________ lbs.
No repetitive squatting, bending or lifting.
One handed job
This restriction is effective until ______________________
May resume full work load/activities effective_______________________
No school until ______________________________________________
Please excuse ________________________ from work, ________________
he/she had to accompany his/her child to the clinic.
(Date)
No gymnasium activity or swimming until_____________________________
Other_________________________________________________________
Sincerely,
________________________________________________________
Signature Title
________________________________________________________
Department
________________________________________________________
Area code & phone number
White Copy - Medical Records
Yellow Copy - Patient
FORM 4898 MR HFDC
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