Address. TELEPHONE NUMBER: I, confirm that (Physician’s/Nurse Practitioner’s/Midwife’s name) (Please print employee’s name) was treated by me on , is or was unable to work (Date) due to (Nature of illness/injury only) PROGNOSIS: Will not return to work: Will return to work on:
Appears in 459 contracts
Samples: Template, Collective Agreement, Collective Agreement
Address. TELEPHONE NUMBER: I, confirm that (Physician’s/Nurse Practitioner’s/MidwifeXxxxxxx’s name) (Please print employee’s name) was treated by me on , is or was unable to work (Date) due to (Nature of illness/injury only) PROGNOSIS: Will not return to work: Will return to work on:
Appears in 80 contracts
Samples: Collective Agreement, Collective Agreement, Collective Agreement
Address. TELEPHONE NUMBER: I, confirm that (Physician’s/Nurse Practitioner’s/Midwife’s name) (Please print employee’s name) was treated by me on , is or was unable to work (Date) due to (Nature of illness/injury only) PROGNOSIS: Will not return to work: Will return to work on:
Appears in 21 contracts
Samples: Collective Agreement, Collective Agreement, Collective Agreement
Address. TELEPHONE NUMBER: I, confirm that (Physician’s/Nurse Practitioner’s/Midwife’s name) (Please please print employee’s name) was treated by me on , is or was unable to work (Date) due to (Nature of illness/injury only) PROGNOSIS: Will not return to work: _ Will return to work on:
Appears in 7 contracts
Samples: Collective Agreement, Collective Agreement, Collective Agreement
Address. TELEPHONE NUMBER: I, _ confirm that _ (Physician’s/Nurse Practitioner’s/Midwife’s name) (Please please print employee’s name) was treated by me on , is or was unable to work (Date) due to (Nature of illness/injury only) PROGNOSIS: _ Will not return to work: _ Will return to work on:: _ (Date)
Appears in 6 contracts
Samples: Collective Agreement, Collective Agreement, Collective Agreement
Address. TELEPHONE NUMBER: I, confirm that (Physician’s/Nurse Practitioner’s/Midwife’s name) (Please please print employee’s name) was treated by me on , is or was unable to work (Date) due to personal illness or injury as of (Nature of illness/injury only) PROGNOSIS: Will not return to work: _ Will return to work on:
Appears in 5 contracts
Samples: Collective Agreement, Collective Agreement, Collective Agreement
Address. TELEPHONE NUMBER: I, confirm that (Physician’s/Nurse Practitioner’spractitioner’s/Midwife’s nameName) (Please please print employee’s name) was treated by me on , is or was unable to work (Date) due to (Nature of illness/injury only) PROGNOSIS: Will not return to work: Will return to work on:
Appears in 2 contracts
Samples: Collective Agreement, Collective Agreement
Address. TELEPHONE NUMBER: I, confirm that (Physician’s/Nurse Practitioner’s/Midwife’s Midwife name) (Please print employee’s name) was treated by me on , is or was unable to work (Date) due to (Nature of illness/injury only) PROGNOSIS: Will not return to work: Will return to work on:
Appears in 2 contracts
Samples: Collective Agreement, Collective Agreement
Address. TELEPHONE NUMBER: I, confirm that (Physician’s/Nurse Practitioner’s/Midwife’s name) (Please please print employee’s name) was treated by me on , is or was unable to work (Date) due to personal illness or injury as of (Nature of illness/injury only) PROGNOSIS: Will not return to work: Will return to work on:
Appears in 2 contracts
Samples: Collective Agreement, Collective Agreement
Address. TELEPHONE NUMBER: I, confirm that (Physician’s/Nurse Practitioner’s/Midwife’s name) (Please print employee’s name) was treated by me on , is or was unable to work (Date) due to (Nature of illness/injury only) PROGNOSIS: Will not return to work: Will return to work on:
Appears in 1 contract
Samples: Collective Agreement
Address. TELEPHONE NUMBER: I, confirm that (Physician’s/Nurse Practitioner’s/Midwife’s 's name) (Please print employee’s name) was treated by me on , is or was unable to work (Date) due to (Nature of illness/injury only) PROGNOSIS: Will not return to work: Will return to work on:
Appears in 1 contract
Samples: Collective Agreement
Address. TELEPHONE NUMBER: I, confirm that (Physician’s/Nurse Practitioner’s/Midwife’s name) (Please please print employee’s name) was treated by me on , is or was unable to work (Date) due to (Nature of illness/injury only) PROGNOSIS: Will not return to work: Will return to work on:
Appears in 1 contract
Samples: Collective Agreement
Address. TELEPHONE NUMBER: I, confirm that (Physician’s/Nurse Practitioner’s/MidwifeXxxxxxx’s name) (Please print employee’s name) was treated by me on , is or was unable to work (Date) due to (Nature of illness/injury only) PROGNOSIS: Will not return to work: Will return to work on:
Appears in 1 contract
Samples: Template
Address. TELEPHONE NUMBER: I, confirm that (Physician’s/Nurse Practitioner’s/MidwifeXxxxxxx’s name) (Please print employee’s name) was treated by me on , is or was unable to work (Date) due to (Nature of illness/injury only) PROGNOSIS: PROGNOSIS Will not return to work: Will return to work on:
Appears in 1 contract
Samples: Collective Agreement