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Return Leave  Form

Return Leave Form

Use a return medical leave 0 template to make your document workflow more streamlined.

_____________________. (name of patient) (date) Restrictions or limitations? Section 2 None Yes Restrictions: ___________________________________________________________________ End Date of restrictions: __________________ (if unknown, please list date of next follow up appointment) Print name and phone number of provider: ____________________________________ Provider’s signature: ____________________________________ Date: ______________ Section 3 This form must be completed prior to...
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