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(To be completed by employee)
I authorise the physician to release necessary information to the below company regarding my condition while under his/her care.
*** To be completed by attending physician ***
Date disability began
Expected return to work date
Nature of disability:
Special complications Work restrictions:
If hospitalized, name of hospital:
Dates: From [Date] To: [Date]
Date of surgery, if any
If pregnancy, expected date of delivery:
Name of Employee