Free Doctor's Note Template and Examples

A doctor’s note template is a guide that shows you what needs to go into a doctor’s note. A doctor’s note is a short document that shows that a person visited a doctor for medical reasons and therefore did not report to work or missed an activity. A doctor’s note may also be used in some circumstances for processing insurance claims.

What to Include in a Doctor’s Note Template

The contents of a doctor’s note are straightforward and are as follows.

Information about the doctor or medical facility. The name, address, and contact information of the doctor or medical facility should be provided. This can be done by the use of an official letterhead normally used by the doctor or facility.
Name of the individual. Naturally, a doctor’s note should state who it applies to, that is, the name of the person who was seen by the doctor.
Date and time. The date of the visit to the doctor is another critical piece of information, especially if the note is regarding an employee who missed work on a particular day or if it is for claiming insurance benefits. If applicable, the time may also be included.
Reason for the doctor’s note. The note should state why it was written. This could be to confirm that the named individual was at the doctor’s office for medical attention. It could also be to notify the employer or school that the individual will need further medical attention on future dates or that he or she should be excluded from certain types of activity. The note may also mention special accommodations that may be needed. For example, an employee with an arm injury may be excused from lifting loads, or an unwell student may require a special diet at school. The note may also mention if, in the doctor’s opinion, the individual is ready to resume work or needs some day of rest or recovery.
Name and signature of the doctor. The person issuing the note should state their name and append their signature at the bottom of the note.
Special note regarding diagnosis. In many jurisdictions, it is against the law for a doctor to disclose specific medical information about a patient without the patient’s consent. Therefore, the doctor’s note may only provide enough information for the employer or school to make any necessary arrangements without divulging more details.

Doctor’s Note Format

Below is a format that may be used to write a doctor’s note.

{Doctor’s Name}

{Doctor’s Address}

Date {00/00/0000}

RE: {Patient Name}

This is to confirm that the above-named person visited my office for medical attention.

After examination, the patient was diagnosed to have mild illness.

The appropriate medication was prescribed and he should be able to resume work on {00/00/0000}.

Sincerely,

{Doctor’s signature}

{Doctor’s name}

Sample Doctor’s note

Here is a sample doctor’s note that includes all the applicable information.

Dr. Jane Doe Smith, MD

123 Doctors’ Plaza

Main Street

Telephone 000 1111 2345

02/02/2021

RE: Jim Ailing

Mr. Ailing visited our clinic today, following a minor accident at home.

I examined him and established that his left arm was sprained at the elbow.

I have prescribed the necessary medicine and two days of rest, after which I recommend that he should only be given desk duties for a further period of at least two weeks.

Regards,

J. D. S.

Jane Doe Smith, MD

Doctor’s Note Template (Word Template)

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Conclusion

A doctor’s note template is simple. However, it is a legal document that could be used in legal proceedings in a work environment. For this reason, it should be carefully written and contain all the details necessary to protect the interests of the employee legally. It should show that the individual in question did indeed visit the doctor on a particular date. Suppose the doctor recommended any specific accommodations. In that case, these should also be clearly stated in the note so that the organization to whom the note was written can make the necessary arrangements for the employee or student.