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Doctors Note Template 02

The document provides a template for a medical restrictions form with fields for patient name, arrival and discharge dates and times, and instructions to return to work, school, or treatment within a certain number of days. It also includes licensing terms for the template prohibiting redistribution without consent and noting the template is for educational use only.

Uploaded by

Sagar Arora
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© © All Rights Reserved
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285 views5 pages

Doctors Note Template 02

The document provides a template for a medical restrictions form with fields for patient name, arrival and discharge dates and times, and instructions to return to work, school, or treatment within a certain number of days. It also includes licensing terms for the template prohibiting redistribution without consent and noting the template is for educational use only.

Uploaded by

Sagar Arora
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as XLS, PDF, TXT or read online on Scribd
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12-121-43827 3948573

SCHOOL / WORK RELEASE


Patient Name
MEDICAL RESTRICTIONS
List all medical restrictions (if any) Arrival Discharged

Date Time Date Time


PATIENT IS TO RETURN TO
Work
School
Inpatient Treatment
Alternative Medical Center
Other:___________________

x WITHIN ________ DAYS OF ABOVE DATE


Medical Professional
*Form is void if not signed
Date

Joseph Medical Center | Justin Road, IN, 34234 |Ph: 999 888 7777 x 323

DEMPLATES.COM LICENSE TERMS & CONDITIONS


________________________________________

You are free to use the downloaded templates for personal uses.
You are not allowed to redistribute this file in any manner unless otherwise you have a written consent.
Any template linked in your website / any online or print medium should be duly attributed with Creative Common 3 licen

Please note - this document is provided only for educational / entertainment use only. Demplates.com is not responsibl
Thanks!!!
ith Creative Common 3 license before you do so.

plates.com is not responsible for any kind of misuse of this document. The hospital names, doctor names and doctors signatures (if
ames and doctors signatures (if any) shown in the doctor note templates are purely a work of art and fiction. Any real life co-inciden
d fiction. Any real life co-incidence with real hospitals / medical centers / doctors are unintentional co-incidence only.
o-incidence only.

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