"Doctor Release Form"

What Is a Doctor Release Form?

Unfortunately, every single one of us can become ill from time to time which may lead to taking an extended leave from your workplace. Your absence may not even be related to an illness. These absences also cover maternity leave and caring for a loved one. In all of these instances, an employer is within their right to request a Doctor Release Form. Download a printable Doctor Release Form template through the link below.

Alternate Names:

  • Physician Release Form;
  • Return to Work Doctor's Note.

This is mainly done so that the employer knows the specific date on which you plan on returning to work and will serve as a reminder to management as to why you required time off in the first place. It is also done so that your employer can plan your working responsibilities and tasks accordingly, making any necessary updates if these are required. After all, many things could have changed at your workplace during your extended time off, depending on how long you were absent. It is important for the employer to make all the relevant adjustments for your return to ensure everything runs smoothly.


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Doctor Release Form
This notice verifies that __________________ (with a mailing address of _____________
_______________________) was seen by __________________ in __________________
on __________________.
They may return to work on __________________ with the following restrictions (check
all that apply):
None.
No heavy lifting (over ______ pounds).
No prolonged standing.
Desk work only.
__________________________________________________________________
__________________________________________________________________
__________________________________________________________________
These restrictions apply through __________________. If symptoms continue and the
individual is unable to perform the full duties of their job by this date, they should make
an appointment with a physician.
_________________________________
_________________________________
Doctor’s Name
Doctor’s Credentials
_________________________________
_________________________________
Doctor’s Signature
Date
©
TEMPLATEROLLER.COM
Doctor Release Form
This notice verifies that __________________ (with a mailing address of _____________
_______________________) was seen by __________________ in __________________
on __________________.
They may return to work on __________________ with the following restrictions (check
all that apply):
None.
No heavy lifting (over ______ pounds).
No prolonged standing.
Desk work only.
__________________________________________________________________
__________________________________________________________________
__________________________________________________________________
These restrictions apply through __________________. If symptoms continue and the
individual is unable to perform the full duties of their job by this date, they should make
an appointment with a physician.
_________________________________
_________________________________
Doctor’s Name
Doctor’s Credentials
_________________________________
_________________________________
Doctor’s Signature
Date
©
TEMPLATEROLLER.COM