MEDICAL 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]