Sample Doctor’s Note for Work

Sample Doctor's Note for Work

A doctor’s note excused a patient from work on Monday and Tuesday due to a serious case of winter fever and throat infection. The doctor prescribed two days of complete bed rest with plenty of fluids and bland food, along with taking the proper dosage of prescribed medicines to cure the ailments.

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Sample Doctor’s Note
(should be on doctor’s letterhead)
[ Date ]
[ Patient ] has been under my care for [ describe period of time (for example, months,
years) ]. [ Patient ] has [ name of condition ] that significantly interferes with [ her/his ]
ability to [ describe limitations, especially related to the relevant impairment ]. As a
result, [ patient ] has a (for example, qualifying disability under the federal Fair Housing
Act and the California Fair Employment and Housing Act, or a medical condition that
will worsen if she does not have access to stable housing, clean water, etc.).
Due to [ patient ]’s condition, exposure to [ name detrimental situation, for example,
tobacco smoke is detrimental to [ her/his ] health and increases the risk of [ patient ]
suffering an adverse event, such as [ describe negative health impact ].
I urge you to grant [ patient ]’s accommodation request to [ describe the accommodation
request (for example, ban smoking in the common areas, allow to move to a vacant unit
away from the drifting smoke, make the surrounding units nonsmoking, release from
rental agreement so can move, etc.) ]. This accommodation is necessary to ameliorate the
conditions of [ patient ]’s disability.
Sincerely,
[ Signature ]
Dr. [ doctor’s name ]
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End of Document
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