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