NSW Health
Medical Clearance Notice under the Public Health
(COVID-19 Self-Isolation) Order (No 4) 2021 [NSW]
To whom it may concern,
I am a registered medical practitioner. I certify that,
Given name: Family name:
DOB: / / (dd/mm/yyyy) Gender: Male Female Prefer not to say
Residential address:
was required to self-isolate from / / (insert isolation onset date) to
/ / (insert De-isolation date) under the Public Health (COVID-19 Self-Isolation) Order
(No 4) 2021 [NSW], or an order that remakes that order, (the Order) to prevent transmission of COVID-19.
This notice confirms that I have assessed them as no longer infectious for COVID-19 and they are medically
cleared under the Order.1
Registered medical practitioner details
Registration
Name:
Number:
M E D 0 0 0
Address:
Signature:
Print and Sign
Telephone:
Date: / /
Email:
Instructions for the patient
Please keep this notice safe, as you may need to show it to NSW Health, your employer, or NSW Police to
demonstrate that you have had COVID-19 and have been released from isolation.
Please note that for six weeks from the end of your isolation period you do not need to be vaccinated for
COVID-19 under any NSW public health order. This letter may be used as evidence to show that you are
exempt for this period of time.
Vaccination is strongly recommended to protect you from getting COVID-19 again. There is no need to delay
vaccination once you have fully recovered from COVID-19.
This document is valid in NSW only. If you are travelling interstate or internationally, please check if this
meets any mandatory vaccination or release from isolation requirements before travelling.
For further information about release from isolation, as well as testing and vaccination after COVID-19,
please see https://www.health.nsw.gov.au/Infectious/factsheets/Factsheets/recovery.pdf
1 Release from isolation must be consistent with the latest version of the NSW Appendix to the Communicable Diseases Network
Australia (CDNA) Series of National Guidelines (NSW SoNG Appendix) – available at https://www.health.nsw.gov.au/Infectious/
covid-19/Documents/SoNG-appendix.pdf
© NSW Health December 2021.
