To be completed by physician or other licensed health care provider.
Date: _________________________________
Employee/patients name:_______________________________________________
Employee/patients job title: _____________________________________________
The above-named employee/patient is currently under my care. The employee/patient cannot perform the essential functions of the employee/patients position with the Montgomery County Government because of the employee/patients serious health condition, which may include complications of pregnancy or childbirth, or recovery from childbirth.
The employee/patients serious health condition began on _________________________________.
(Please provide date)
I estimate that the patient will be able to return to work on _________________________________.
(Please provide date)
Name of licensed health care provider: _______________________________________________
(Please print)
Professional title ___________________________________________________
(Medical doctor, licensed physician therapist, etc.)
Work phone: _________________________________
Other phone: _________________________________
Address: __________________________________________________________________________
Signature: __________________________________________________
Please return this form to the employee/patient.