Doctor’s Note

Purpose: This document serves as a formal verification from a licensed medical professional that the person named below has been examined and diagnosed with a medical condition justifying time off from work or school as indicated.

Patient Information

Full Name: {name} {surname}
Date of Birth: {dateOfBirth}
Patient ID (if applicable): {patientId}

Date of Consultation

Consultation Date: {consultationDate}
Physician: Dr. {doctorName}
Medical Facility: {facilityName}

Health Condition Summary

The above-named patient was evaluated and diagnosed with a medical condition that warrants a period of rest and recovery. Based on clinical judgment, a medical leave is recommended as outlined below.

Medical Leave Recommendation

Recommended Leave Start Date: {leaveStartDate}
Recommended Leave End Date: {leaveEndDate}

{#hasFollowUp}

{/hasFollowUp}

Restrictions (if applicable)

{^hasRestrictions}There are no activity restrictions during this period.{/hasRestrictions}

{#hasRestrictions}

• {restrictionDetail}

{/hasRestrictions}

Additional Notes

{additionalNotes}

Physician Information

Full Name: Dr. {doctorName}
Medical License Number: {licenseNumber}
Phone: {contactPhone}
Email: {contactEmail}

Signature

Date: {signatureDate}
Signature: ___________________________