Work Release Form

The employee/patient,   First Name   Last Name , was seen in this facility on   Date   .

The patient may return to work on   Date   with following restrictions:

None            
No heavy lifting over            1   pounds.   
No prolonged standing.    
Desk work only.    
Other:     2   .

The restrictions would no longer be necessary after   Date   . The employee should be participate fully in work duties after this date.

HOWEVER, if symptoms continue and the employee is unable to perform the duties of their job, employee should make an another appointment with their physician.