SEARS MEDICAL ASSOCIATES



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|McEllistrom Medical Center |

|5313 Grant Ave, New York, NY | Phone: (555) 555-5555 | Fax: (555) 555-5555 |

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|Grant Davenfield, M.D. ( Benjamin Davis, Jr., M.D. ( Scott Carlson M.D. ( Megan Braft, M.D. |

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Patient: DOE, JANE Date: 11/16/2017

Health Care Provider: Davis, Ben, M.D.

REPORT TO EMPLOYER – MEDICAL TREATMENT OF EMPLOYEE

The above employee has been evaluated today (date above). The physician has instructed the employee concerning further work, as described below: ACCIDENT LAST WEDNESDAY 11-8-17.

WORK STATUS:

( Can return to regular work now

( OFF work, Scheduled Return to Work on ____/____/____

( Will require Light Duty, as follows:

( No water or solvent exposure.

( Sitting work only -- No walking or prolonged standing.

( Limit walking, not more than 100 ft. per hour.

( Limit arm use, not to lift over five lb. with injured arm.

( No lifting whatsoever.

( Light lifting only, not more than 20 lbs.

( Estimated duration of light duty _________________________

Re-evaluation scheduled on ________/2017.

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|(Stamp of Medical Practitioner-Optional) | |

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McEllistrom Medical Center

5313 Grant Ave, New York, NY (555) 555-5555 | (555) 555-5555

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