New Jersey Electrical Workers Temporary Disability Benefit Fund Form Page 2

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PHYSICIAN’S STATEMENT
Patient’s Name _________________________________________________________________ Age __________
Nature of Sickness or Injury _____________________________________________________________________
_____________________________________________________________________________________
Did This Sickness or Injury Arise Out of Patient’s Employment? ________________________________________
If Yes, Explain ________________________________________________________________________
Is This Disability Due to Pregnancy? ______________________________________________________________
Nature of Surgical or Obstetrical Procedure, If Any (Describe Fully) _____________________________________
____________________________________________________________________________________________
Date Performed ________________________________________________________________________
Give Dates of Treatment
Office ________________________________________________________________________________
Home ________________________________________________________________________________
Hospital ______________________________________________________________________________
The Patient Has Been Continuously Disabled (unable to work) From______________ Through _______________
If Still Disabled, When Should Patient Be Able To Return To Work? _____________________________________
Restrictions: __________________________________________________________________________________
Remarks: ____________________________________________________________________________________
____________________________________________________________________________________________
____________________________________________________________________________________________
Name of Physician ____________________________________________ Telephone (_____) ________________
Street Address ________________________________________________________________________________
City, State, Zip ________________________________________________________________________________
Physician’s
Date _________________________
Signature _________________________________________

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