DOCTOR'S NOTE

[Practice name]
[Address]
[Phone and email]

Date issued: [Date]
To: [Employer or school, or To whom it may concern]

Re: [Patient's full name]
Date of birth: [Date]

I assessed [patient name] [in person, by video, or by phone] on [date of the visit].

Unable to [work or attend school]: [From first date to last date, or not needed]
Dates before the visit: [None, or the dates, based on what the patient told me]
Expected return: [Date, or the date I will reassess]
Restrictions on return: [None, or what they should not do and until when, e.g. no gym or sports for 2 weeks]
Diagnosis: [Only if the patient asks for it to be included; otherwise delete this line]

To confirm that this practice issued this note, call [practice phone]. We will confirm only that the note is genuine.

[Your name, credentials]
[License or registration number]
[Signature]