John Smith">
John Smith, M.D., P.A. Return to Work/School Form
12345 Maple Drive
AnyCity, Florida 33000
phone: 555-123-4567
fax: 555-123-4568
CERTIFICATE TO RETURN TO WORK
NAME: __________________________________
has been under my care from _________ to _________
and is able to return to work on ____________________
Nature of illness / injury __________________________
[ ] restrictions [ ] no restrictions
Comments ____________________________________
_____________________________________
_____________________________________
_______________________, M.D.
CERTIFICATE TO RETURN TO SCHOOL
NAME: ___________________________________
has been under my care from _________ to _________
and is able to return to school on __________________
Nature of illness / injury __________________________
[ ] restrictions [ ] no restrictions
Comments ____________________________________
____________________________________
____________________________________
____________________, M.D.