Doctor’s Note with Signature

Patient Name:                                                           

Date of Birth:                                                             

Date of Visit:                                                             

To Whom It May Concern,

This is to certify that Mr./Ms.                                                              was evaluated at our medical facility on the above-mentioned date. The patient has been diagnosed with                                                              and has been advised to take medical leave from          /         /         to          /         /         for proper rest and recovery.

If further clarification is required, please feel free to contact our office.

Sincerely,

Dr.                                                             

Clinic/Hospital Name:                                                             

Contact Information:                                                               

Date:          /         /