Doctor'S Medical Certificate Template

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DOCTOR’S MEDICAL CERTIFICATE
RE: Recommendation for use of prescribed restraint
Client’s full name:
Date of birth:
Client’s Diagnosis:
Telephone:
Parent/Carer full name:
Address:
This letter certifies that _______________(client name) has been diagnosed with
the permanent disability of _______________.
As a result, he/she is unable to travel in his/her standard vehicle seat, and
requires _________ (the restraint you are applying for) for use in his
family/personal vehicle when travelling.
I recommend that the ___________(restraint name) is used by _______ (client
name) to provide _____________________ (whatever it is helping with i.e.
posture, behaviour, safety etc) during travel.
Please refer to advice to parents form from prescriber, ___________
(Occupational Therapist).
Doctor’s Signature:
Stamp (if applicable):
Doctor’s name:
Date:
Doctor’s Contact details (email/phone):
Created April 2016 by the WA Travel Safe Interagency Group -
Adapted from
AS/NZ 4370:2013 and AS/NZ 1754: 2013.

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