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Return To Work Medical Evaluation Form

To receive medical verification from your employees have their medical professional fill out the form below.

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Return To Work Medical Evaluation Form

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Return To Work Medical Evaluation Form

Employee's Name: _________________________ ID# ____________________
Date of injury/surgery/onset or onset of illness: __/__/___ Date of Exam: ______
Diagnosis or description of injury/surgery/illness: _________________________

The patients return to work status is:

[___] Return to regular work. Date: ____/____/____
[___] Able to return to work with noted restrictions. Date: ____/____/____
[___] Unable to return to work until next evaluation. Date: ____/____/____
[___] Referred to health care provider. Name ________ Date: ____/____/____

Lifting Restrictions:

[___] None
[___] 40 - 50 lbs.
[___] 30 - 39 lbs.
[___] 20 -29 lbs.
[___] 10 - 19 lbs.

Follow Up Plan of Treatment:

[___] None
[___] Return visit on: ______________ at________a.m./p.m.
Additional Comments: ______________________________________



Health Care Provider's Signature ______________________________

Print Name ________________________________ Date ___________
Phone Number: ____________________________________________
Address City and State Zip: ___________________________________

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