Disability Certificate Template

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Disability Certificate
Doctor’s name
Address & Details
Office Phone
Office Fax
Patient’s name
Patient
Work related
Date of Injury
Company
or illness
Non Work Related
This is to certify that
has been under my professional care,
and was totally incapacitated from
to
This is to certify that
has been under my professional care,
and was partially incapacitated from
to
This is to certify that
has been under my professional care,
and will be totally incapacitated from
to
This is to certify that
has been under my professional care,
and will be partially incapacitated from
to
Remarks & Comments
Doctor’s Signature
Date

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