Employee Physician's Report

Date:

Doctor:

Re:[employee's name]

Dear Doctor:

The above referenced employee has been absent from work on the
days noted below. We have been advised that the employee has
been receiving treatment from you. It is our company policy to
verify prolonged medical absences. Accordingly, we would
appreciate your completing the form below and returning it to
our personnel office.

Dates of absences:

Sincerely,


Date:

I consent to the release of the above information.

____________________________
Signature of Employee

- - - - - - - - - - - - - - - - - - - - - - - - - - - - - -

I certify that [Name] has been under my medical
care during the above absences and that the absences listed were
medically necessary or reasonable based on the employee's
medical condition.

Date:

____________________________
Signature of Doctor


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