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Medical Leave Letter Template
A medical leave letter supports a patient’s leave from work for their own health: that they can’t work from a date, for how long, and what their return may need. Copy the blank letter or download it, with a leave after surgery, an extension, and the rules on leave certificates, place by place.
- Free, no account needed
- Word and text downloads
- Two filled examples
Blank medical leave letter template
FreeMEDICAL LEAVE LETTER [Practice name] [Address] [Phone and email] Date: [Date you write the letter] To: [Employer, human resources, or leave administrator, or To whom it may concern] Re: [Patient's full name] Date of birth: [Date] Employee or claim number: [If the employer or program gave one; otherwise delete this line] Letter type: [New leave, or extension of the leave that began on date] ASSESSMENT I assessed [patient name] [in person, by video, or by phone] on [date of the visit]. Care so far: [How long I have been treating them for this, or first visit] LEAVE [Patient name] is unable to work for medical reasons from [first day off work]. Expected length: [Number of weeks, to last day of leave] Pattern: [Continuous, or reduced hours or occasional days off, with how many] Next review: [Date I will reassess, if the return date isn't known yet] Expected due date: [Only if the patient is pregnant and the employer or program asked for it; otherwise delete this line] EXTENSION [For an extension only: the leave already approved, the further time needed and to what date, why more time is needed in general terms, and the outlook for a return. Otherwise delete this section] RETURN TO WORK Expected return: [Date, or to be confirmed at the review] What the return may need: [Full duties, or a graded return, restrictions, or time for appointments, to follow in a return-to-work note] DIAGNOSIS [Not included, or with the patient's consent: the diagnosis or a plain description they agree to] The patient asked for this letter and agreed to what it says. [Your name, credentials] [License or registration number] [Signature] To verify this letter: [Practice phone]
Use it for
- Leave after surgery
- Extending an approved leave
- Mental health leave
- Pregnancy complications and bed rest
- Leave as an accommodation
Two filled examples. Every part, filled in.
Each one follows the template. Use them to judge how much detail every part needs.
Medical leave letter: 6 weeks off after a hip replacement
Orthopedic surgery clinic, pre-operative visit; letter for the employer’s human resources team
Patient and employer
Letter for a 61-year-old library technician, addressed to her employer’s human resources team. She asked for the letter and agreed to its content.
Assessment
I assessed her in person on Thursday, October 15, 2026, before her planned surgery on Monday, October 26, 2026.
Leave
Unable to work for medical reasons from Monday, October 26, 2026, for 6 weeks, to Sunday, December 6, 2026. The leave is continuous. If the surgery date changes, I will send an updated letter.
Return
Expected back at work on Monday, December 7, 2026, after her review on Thursday, December 3. She may need a graded return and limits on lifting, ladders, and shelving at first. I will set them out, with how long they last, in a return-to-work note after the review.
Diagnosis
Planned right hip replacement. Included at her request, so her team knows why she will be away.
Forms
Her employer’s short-term disability insurer sent its own attending physician statement. The same dates go on it.
Signed
Orthopedic surgeon, with credentials, license or registration number, and signature, on clinic letterhead, with the clinic’s phone number for verification. Issued October 15, 2026.
Medical leave extension letter: 4 more weeks
Family physician, in-person follow-up; diagnosis not shared, at the patient’s request
Patient and employer
Letter for a 47-year-old software support analyst, to his employer’s leave administrator. He asked for the extension and agreed to the letter’s content.
Assessment
I assessed him in person on Tuesday, October 20, 2026. I have seen him 4 times since his leave began on Monday, September 14, 2026.
Leave so far
His approved leave runs from Monday, September 14, to Sunday, October 25, 2026: 6 weeks.
Extension
He remains unable to work for medical reasons. I recommend a further 4 weeks of leave, from Monday, October 26, to Sunday, November 22, 2026.
Why more time
His treatment is under way and he is improving, but not yet enough to manage the concentration and workload his job needs. Recovery has taken longer than I first estimated. I considered whether reduced hours now could replace the extra leave; he isn’t ready for them yet.
Outlook
I expect him to be able to start a graded return on Monday, November 23, 2026. I will review him on Tuesday, November 17, and give him a return-to-work note with the schedule.
Diagnosis
Not included, at his request. The dates, why more time is needed, and the outlook are what the employer needs to consider the extension.
Forms
If the leave administrator sends its own form to recertify the leave, the same dates and outlook go on it.
What employers and programs can ask for. Checked October 2026.
Leave laws and benefit programs set when a certificate can be required and what it covers. Employer policies, collective agreements, disability plans, and state and provincial programs can add their own; check the rules where your patient works.
United States, federal: FMLA leave
Eligible employees of covered employers can take up to 12 workweeks of unpaid, job-protected leave in a 12-month period for a serious health condition that makes them unable to perform the functions of their job. Their group health benefits continue on the same terms.
United States, federal: FMLA certification
The employer may require a certification from a health care provider, generally within 15 calendar days of asking. The DOL’s Form WH-380-E is optional, and the provider may, but is not required to, give a diagnosis. Recertification is generally limited to every 30 days and only with an absence, but the employer may ask sooner when the employee requests an extension of leave.
United States, federal: leave as an ADA accommodation
Leave, including more leave than a policy allows, can be a reasonable accommodation. With the employee’s permission, the employer may ask the health care provider about the need for leave, how much, and whether other accommodations could reduce it; for an extension, about the need for more time and the likelihood of a return. Indefinite leave, when the employee can’t say whether or when they will return, doesn’t have to be granted.
Canada, federally regulated employers
Employees are entitled to up to 27 weeks of medical leave for personal illness or injury, among other reasons, and give written notice of its start, expected length, and any change. After a leave of at least 5 consecutive days, the employer may, in writing within 15 days of the return, require a certificate from a health care practitioner that the employee couldn’t work for that period.
Canada, EI sickness benefits
Employment Insurance sickness benefits pay for up to 26 weeks. The patient needs a medical certificate showing that they can’t work for medical reasons, and for about how long.
Ontario: leave as a human rights accommodation
A person seeking accommodation may generally be expected to share their limitations or needs, whether they can do the essential duties, and, when on leave, regular updates on when they expect to return. The employer generally isn’t entitled to the diagnosis, cause, symptoms, or treatment unless they clearly relate to the accommodation or the needs are complex or unclear.
United States, federal: pregnancy-related limitations
Under the Pregnant Workers Fairness Act, paid or unpaid leave is one possible reasonable accommodation, for example to recover from childbirth. An employer doesn’t have to ask for documentation; when it’s reasonable to ask, it may seek only the minimum needed to confirm the condition, that it’s related to pregnancy, childbirth, or related medical conditions, and the change at work that’s needed.
Ontario: stopping work early in pregnancy
An employee who stops work because of an illness or complication caused by the pregnancy can treat the time as sick time and start pregnancy leave later. If the employer asks, she provides a certificate from a doctor, midwife, or nurse practitioner stating the due date and that she couldn’t perform the duties of her position because of the complication.
What goes in each part.
Practice and recipient
Who wrote the letter, who it goes to, and whether it starts a leave or extends one.
- Your practice’s name, address, and phone, on letterhead
- The date you write the letter
- The employer, human resources, or leave administrator, if the patient named one
- Any employee or claim number the employer or program gave
- Whether this is a new leave or an extension
Avoid: Sending it to the employer yourself without the patient’s consent. Give it to the patient unless they agree otherwise.
Assessment
When and how you assessed the patient, and how long you have been treating them.
- The patient’s full name and date of birth
- The real date of the visit, and whether it was in person, by video, or by phone
- How long you have been treating them for this, if it’s not the first visit
Avoid: Certifying a leave you haven’t assessed. If someone else is treating the condition, say so, or let them write it.
Leave dates
The day the patient stops work, how long you expect them to need, and when you’ll look again.
- That the patient can’t work for medical reasons, from a date
- The expected length in weeks, and the last day of leave
- Continuous leave, or reduced hours or occasional days off, with how many
- A review date, if you can’t yet say when they’ll be fit
- The expected due date, if the patient is pregnant and the employer or program asked for it
Avoid: “Off until further notice.” Give an expected length, or the date you will reassess.
Extension
When a leave needs more time, the reader will want to know why, and whether a return is still expected.
- The leave already approved, with its dates
- The further time needed, and the new last day
- Why more time is needed, in general terms, such as treatment still under way or a slower recovery
- The outlook for a return, and whether reduced hours or other changes could shorten the leave
Avoid: Sending the first letter again with a new date. An extension needs a reason and an outlook.
Return to work
When you expect the patient back, and what the return may need, so the employer can plan.
- The expected return date, or that you’ll confirm it at the review
- Whether a graded return, restrictions, or time for appointments are likely
- That you’ll set them out in a return-to-work note
Avoid: Listing detailed restrictions weeks ahead. Assess them closer to the return.
Diagnosis and consent
Usually left out. An employer generally needs to know that the patient can’t work, for how long, and what the return needs.
- No diagnosis, unless the patient asks you to include it
- If they do: the diagnosis, or a plain description they agree to
- That the patient asked for the letter and agreed to its content
Avoid: Adding the diagnosis to make the leave look more convincing. The dates and outlook carry the letter.
Signature and verification
Your details, so the letter can be traced to you and checked.
- Your name and credentials
- Your license or registration number
- Your signature
- A practice phone number for verification
Avoid: Saying more than “yes, I wrote it” when someone calls to check. Share nothing else without the patient’s consent.
Common mistakes, and how to avoid them.
An open-ended leave
“Off until further notice” leaves the employer unable to plan or approve the leave. Give an expected length, or the date you will reassess.
The diagnosis by default
An employer generally needs to know that the patient can’t work, for how long, and what the return needs. Add the diagnosis only if the patient agrees.
An extension with no reason
A new date on its own invites questions. Say in general terms why more time is needed, and what the outlook for a return is.
A letter where a form is needed
Leave programs, benefit plans, and disability insurers often have their own certification. Ask the patient what the employer or program sent before you write.
More leave than you expect them to need
Write the time you think the patient needs, not the most a policy allows. If you’re unsure, give a shorter period and a review date, and extend it if needed.
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Frequently asked questions.
What should a medical leave letter from a doctor include?
The date you assessed the patient, that they can’t work for medical reasons from a date, the expected length or a review date, and what the return may need. Sign it with your name, credentials, and license or registration number. Leave out the diagnosis unless the patient asks for it.
How do I write a letter to extend medical leave?
Give the leave already approved, the further time needed and the new end date, why more time is needed in general terms, and the outlook for a return. Employers often ask about these when they decide on an extension.
Does a medical leave letter need the diagnosis?
No. An employer generally needs to know that the patient can’t work, for how long, and what the return needs. Include the diagnosis only with the patient’s consent.
How long can a doctor put someone on medical leave?
Write the time you expect the patient to need, with a review date if you’re unsure, and extend it if needed. How long the job is protected or paid depends on the law, the employer’s policy, and any benefit plan where the patient works.
Can I write a doctor’s note for bed rest in pregnancy?
Yes, if you have advised the patient to stop work. Say that she can’t work from a date, the expected length or review date, and the due date if the employer or leave program asks for it. Leave the complication out unless she agrees.
Can I write a medical leave letter for depression or anxiety?
Yes. Write it as you would for any condition: unable to work for medical reasons, the dates, a review date, and the outlook. The patient decides whether the diagnosis goes in.
Show all questions
What if the employer or insurer sends its own form?
Complete their form. Leave laws, benefit programs, and disability insurers often use their own certification, and a letter may not be accepted in its place. The same dates and outlook go on it.
Does the employer need updates during the leave?
It depends on where the patient works. Some rules expect regular updates on the expected return; others limit them once a fixed return date has been given. A clear return or review date in each letter keeps updates simple.
Is this medical leave letter template free?
Yes. Copy it, or download it as a Word or text file. No account needed.
Can Vero write a medical leave letter from my visit?
Yes. Paste this template into Vero, and it drafts the letter from your visit, with the dates and outlook you discussed. Review and edit it, then export it to PDF or Word, print it, or email it.
More templates, and guides.
Doctor’s note template
For work or school: the visit, the dates off, the return, and any limits.
Return-to-work note template
To an employer: full or modified duties, the restrictions, how long they last, and the review date.
Workplace accommodation letter template
To an employer: what the condition limits, the change that would help, how long, and answers to the employer’s questions.
Pregnancy accommodation letter template
To an employer: the pregnancy-related limitation, the change needed at work, and how long it lasts.
Lactation accommodation letter template
For pumping or breastfeeding at work: the breaks, the space, any medical reason, and an end date.
Caregiver leave letter
Leave to care for a family member, rather than for the patient’s own health.
Vero Documents
Fill leave, disability, and insurer forms from the visit and the chart.
Medical forms library
Leave, disability, and insurer forms, with official links and how to file.
Your template. Filled in from the visit.
Vero writes your notes and letters in the templates you choose, so you review instead of type.
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