Return To Work Form
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1Return to Work Certificate
Name
Age
Phone
Company
Date of
name &
Injury or
Address
illness
Patient may return to work with no limitations or restrictions from:
Patient may return to work on
with the below mentioned restrictions & limitations.
Limits & Restrictions
Duration of activity per day
Lifting limitations & restrictions
Duration of standing activity
Walking duration & restrictions
Seated activity & restrictions
Driving limits
Activities to be specifically avoided
Others
Comments & Notes
Doctor’s
Address &
name &
Contact
signature
details
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Parent category: Business