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Doctor Work Release
As an employee of this firm you must present this Work Release Form filled out by your doctor, to your manager or supervisor, on the day of or before you return to work. Your supervisor or manager will then turn in a signed Work Release Form to the Human Resources Department to be placed in your permanent file.

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


Doctor Work Release TemplateForm 1369
Format: Word PDF
Category: Medical, Doctor Office
Type: Form
Doctor’s Return to Work Form



Employee’s Name: ____________________________________________ Date: ___/___/_____

Doctor’s Name: ________________________________________________________________

Doctor’s Phone Number: _________________________________________________________

To be completed by the Doctor:

After reading the attached job description and the specific work tasks for the specified job

description please complete both A and B below and sign and date below.

A. The above named employee has been released by the above listed doctor to return to work on a

FULL DUTY status as of ___/___/_____ with NO RESTRICTIONS.

B. The above named employee has been released by the above named doctor to return to work on

___/___/_____ with the following WORK RESTRICTIONS through ___/___/_____.

Restrictions: ____________________________________________________________________________

______________________________________________________________________________________

______________________________________________________________________________________

______________________________________________________________________________________

______________________________________________________________________________________

______________________________________________________________________________________

______________________________________________________________________________________

______________________________________________________________________________________


Doctor’s Signature: _____________________________________________________Date: ___/___/_____


Employee’s Signature: __________________________________________________Date: ___/___/_____