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    Return To Work Form PDF

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    Dhayu Mart Hindrasyah Pandia
    Patient may return to work with no limitations or restrictions. Lifting limitations and restrictions duration of activity per day Walking duration and restrictions Seated activity and restrictions Driving limits Activities to be specifically avoided.

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    © All Rights Reserved
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    Return To Work Form PDF

    Uploaded by

    Dhayu Mart Hindrasyah Pandia
    25 views1 page
    Patient may return to work with no limitations or restrictions. Lifting limitations and restrictions duration of activity per day Walking duration and restrictions Seated activity and restrictions Driving limits Activities to be specifically avoided.

    Original Title

    Return_To_Work_Form.pdf

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    © © All Rights Reserved

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    Patient may return to work with no limitations or restrictions. Lifting limitations and restrictions duration of activity per day Walking duration and restrictions Seated activity and restrictions Driving limits Activities to be specifically avoided.

    Copyright:

    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd
    Download as pdf or txt
    25 views1 page

    Return To Work Form PDF

    Uploaded by

    Dhayu Mart Hindrasyah Pandia
    Patient may return to work with no limitations or restrictions. Lifting limitations and restrictions duration of activity per day Walking duration and restrictions Seated activity and restrictions Driving limits Activities to be specifically avoided.

    Copyright:

    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd
    Download as pdf or txt
    You are on page 1of 1

    Name Age Phone

    Company
    name &
    Address

    Date of
    Injury or
    illness


    Patient may return to work with no limitations or restrictions from:

    Patient may return to work on with the below mentioned restrictions & limitations.

    Limits & Restrictions
    Duration of activity per day
    Lifting limitations & restrictions
    Duration of standing activity
    Walking duration & restrictions
    Seated activity & restrictions
    Driving limits
    Activities to be specifically avoided
    Others
    Comments & Notes

    Doctors
    name &
    signature

    Address &
    Contact
    details


    Return to Work Certificate
    www.FreePrintableMedicalForms.com

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