SICK NOTE / MEDICAL CERTIFICATE

[Clinic name]
[Address]
[Phone]

Date: [Date you write the note]

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

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

ASSESSMENT
I assessed [patient name] on [date of assessment].
Visit: [In person, or virtual by video or phone]
Reported by the patient: [When the illness started, and any days missed before the visit]

ABSENCE
Unable to work or attend school from [first day] to [last day], inclusive.
Expected return: [Date]
Reassessment: [Date, if the return date isn't known yet, or not needed]

FITNESS ON RETURN
[Fit for full duties, or fit with these restrictions: what the patient can't do, and for how long]

DIAGNOSIS
[Not included, or with the patient's consent: the diagnosis or a plain description]

The patient asked for this note and agreed to its content.

[Your name, profession]
[College name and registration number]
[Signature]

To verify this note: [Clinic phone or email]