Common use of Care Professional to complete Clause in Contracts

Care Professional to complete. From the date of this assessment, the above will apply for approximately: 6-10 days 11- 15 days 16- 25 days 26 + days Have you discussed return to work with your patient? Yes No Recommendations for work hours and start date (if applicable): Regular full time hours Modified hours Graduated hours Start Date: dd mm yyyy Is patient on an active treatment plan?: Yes No Has a referral to another Health Care Professional been made? Yes (optional - please specify): If a referral has been made, will you continue to be the patient’s primary Health Care Provider? No Yes No

Care Professional to complete. From the date of this assessment, the above will apply for approximately: ☐ 6-10 days 11- ☐ 11-15 days 16- ☐ 16-25 days 26 ☐ 26+ days Have you discussed return to work with your patient? ☐ Yes ☐ No Recommendations for work hours and start date (if applicable): ) ☐ Regular full time hours ☐ Modified hours ☐ Graduated hours Start Date: dd mm yyyy Is patient on an active treatment plan?: ? ☐ Yes ☐ No Has a referral to another Health Care Professional been made? ☐ Yes (optional - – please specify): ☐ No If a referral has been made, will you continue to be the patient’s primary Health Care Provider? No ☐ Yes ☐ No

Care Professional to complete. From the date of this assessment, the above will apply for approximately: 6-10 days 11- 15 days 16- 25 days 26 + days Have you discussed return to work with your patient? Yes No Recommendations for work hours and start date (if applicableifapplicable): Start Date: dd mm yyyy Regular full time hours Modified hours Graduated hours Start Date: dd mm yyyy Is patient on an active treatment plan?: Yes No Has a referral to another Health Care Professional been made? Yes (optional - please specify): If a referral has been made, will you continue to be the patient’s primary Health Care Provider? No Yes No