DIY Legal Forms

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Disability Certificate

(To be completed by employee)

Employee's name:

Home phone:

Home address:

I authorise the physician to release necessary information to the below company regarding my condition while under his/her care.

Employee's [signature]

Date:

*** To be completed by attending physician ***

Date disability began

Expected return to work date

Nature of disability:

Special complications Work restrictions:

Work restrictions:

Date(s) seen:

If hospitalized, name of hospital:

Dates: From [Date] To: [Date]

Date of surgery, if any

Procedure:

If pregnancy, expected date of delivery:

Physician's name:

Address:

Phone number:

Return to:

Signature

Name of Employee

Date: