Common use of Physician's Statement Clause in Contracts

Physician's Statement. I examined the above-named patient on Nature of injury or illness CHECK ONE: Patient may return to work immediately. Patient may work a light duty assignment. Patient unable to work due to this injury/illness from date) through (date) For the following reasons: Date patient can return to work Restriction or comments Was this condition reported to you as job related? Date: Attending Physician's Signature Address