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Permission To Return To Work
The following letter can either be given by a chiropractor or you can give to your chiropractor to fulfill. The note will give permission to return to work or school, so that your employer is aware of your evaluation and any limitations that might be associated with injuries that were treated.

Free Sample Template
Format: Word PDF
# of Pages: 1
Printable: Yes

Permission To Return To Work TemplateForm 1747
Format: Word PDF
Category: Medical, Chiropractor
Type: Form

Chiropractor Permission To Return To Work

[Your Name]


[City, State, Zip]

[Date of letter]

[Recipientís Name]


[Company Name]


[City, State, Zip]

Re: Patient John Doe

Dear [Recipientís name],

I am writing to you today to certify that the above named patient has been under my care since: ___/___/_____. I advised him on that date to discontinue working until further notice.

As of this date he is:

___ Still unable to return to work.

___ Has sufficiently recovered to resume a normal workload and schedule.

___ Has sufficiently recovered to return to work with the following limitations:

1. ___________________________________________________________________________________

2. ___________________________________________________________________________________

3. ___________________________________________________________________________________

Best regards,

[Your Signature]