Medical Certificate (with disclaimer & additional notes based on consent)

Practice Name: [Enter Clinic or Practice Name] (only include if mentioned) Contact Number: [Enter Practice Contact Number] (only include if explicitly mentioned) Date of Certificate: [Enter Date of Completion] (only include if explicitly mentioned) To Whom It May Concern, This is to certify that [Enter Patient’s Full Name] (only include if explicitly mentioned) was examined at this clinic on [Enter Date of Examination] (only include if explicitly mentioned), and in my professional opinion, they have a medical condition that renders them unfit for work and/or normal daily activities from [Enter Start Date of Recommended Leave] to [Enter End Date of Recommended Leave] (only include if leave period has been specified). [Enter Optional Additional Certification Wording Based on Consent or Specific Request] (only include if the patient consents to sharing diagnosis or medical detail; otherwise, omit condition-specific wording completely. If included, write as a full sentence and ensure clarity and appropriateness for third-party review.) Based on the examination findings, I confirm that [Enter Patient’s Full Name] (only include if explicitly mentioned) is now considered medically fit to return to work or resume their usual activities as of [Enter Return-to-Work Date] (only include if explicitly stated or relevant to the consultation). If there are any ongoing restrictions or modified duties recommended, these are outlined in the remarks section below. Remarks: [Enter any additional relevant comments or recommendations] (only include if applicable; use full sentences to document return-to-work conditions, required follow-up, partial duties, or non-disclosure of condition based on patient preference) Healthcare Provider Details: Provider Name & Signature: [Enter Healthcare Provider’s Name] (only include if explicitly mentioned) Qualification: [Enter Qualifications] (only include if specified) Provider Number: [Enter Provider Number] (only include if applicable) Email: [Enter Provider Email Address] (only include if explicitly mentioned) Disclaimer: This medical certificate has been issued based on clinical judgment and information obtained during the consultation. It is intended solely for the purpose of verifying medical status related to employment, insurance, or other official purposes. Reproduction or alteration of this certificate without consent is not permitted. (Never come up with your own patient details, diagnosis, dates, assessment, or recommendations – use only the transcript, contextual notes, or clinical documentation as a reference for the information included in your note. If any information related to a placeholder has not been explicitly mentioned in the transcript, contextual notes, or clinical note, you must not state the information has not been explicitly mentioned in your output – just leave the relevant placeholder or omit the paragraph completely. Use one paragraph per section and write in full sentences unless otherwise formatted in the original note.)