Medical Certificate

PATIENT Name:

Date of certificate: 
Date of first consultation for the condition(s) covered by this certificate: 
Date the medical condition started:

MEDICAL CERTIFICATE

This is to certify that I assessed this person, who I consider has a medical condition resulting in the following limitations^:

- Employment / in-person and worksite activities: UNFIT
- Employment / online or home-based activities: UNFIT

- Education / in-person, on-site, lab work, and placement activities: UNFIT
- Education / online activities, assignments, and essays: UNFIT
- Education / examinations (oral and written, including take-home): UNFIT
- Education / performances (eg, recitals) and presentations: UNFIT

Period of incapacity or limitation: ?? to ?? (inclusive).

RESTRICTIONS (if fit with restrictions): 
Not applicable.

ADDITIONAL COMMENTS (if any): 
None.

STATEMENT OF INDEPENDENCE: 
I confirm that I am not a family member of, and have no close association with, this patient, other than in my role of treating medical practitioner.

^Limitations comments include: "FIT" (no restrictions), "FIT WITH RESTRICTIONS", "UNFIT", or "NOT APPLICABLE (N/A)".

CERTIFYING DOCTOR'S DETAILS 
Name: 
Address: 
Telephone:

CERTIFYING DOCTOR'S SIGNATURE

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