Medical certificate

PATIENT Name:

Date of certificate: 
Date of first consultation for the condition(s) covered by this certificate: 
Date the medical condition started:

MEDICAL CERTIFICATE

Codes:
1 = Permitted, no restrictions, fit
2 = Not permitted, unfit
R = Permitted with restrictions/limitations

This is to certify that I assessed this person, who I consider has a medical condition resulting in the following limitations:

Employment / in-person and worksite activities: 1

Employment / online or home-based activities: 1

Education / in-person, on-site, lab work, and placement activities: 1

Education / online activities, assignments, and essays: 1

Education / examinations (oral and written, including take-home): 1

Education / performances (eg, recitals) and presentations: 1

Period covered by this certificate (dates are inclusive):
  from: 
  to:

RESTRICTIONS (if applicable):

ADDITIONAL COMMENTS (if any):

STATEMENT OF INDEPENDENCE: 
I confirm that I am not a family member of this person and have no close association with this person, other than in my role as a treating medical practitioner.

CERTIFYING DOCTOR'S DETAILS 
Name: 
Address: 
Telephone:

CERTIFYING DOCTOR'S SIGNATURE

Medical certificate

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