Common use of Address Clause in Contracts

Address. TELEPHONE NUMBER: I, confirm that (Physician’s/Nurse Practitioner’s/▇▇▇▇▇▇▇’s name) (Please print employee’s name) was treated by me on , is or was unable to work due to (Nature of illness/injury only) PROGNOSIS: Will not return to work:

Address. TELEPHONE NUMBER: I, confirm that (Physician’s/Nurse Practitioner’s/▇▇▇▇▇▇▇Practitioner’s/Midwife’s name) (Please print employee’s name) was treated by me on , is or was unable to work due to (Nature of illness/injury only) PROGNOSIS: Will not return to work: Will return to work on:

Address. TELEPHONE NUMBER: I, confirm that (Physician’s/Nurse Practitioner’s/▇▇▇▇▇▇▇Practitioner’s/Midwife’s name) (Please print employee’s name) was treated by me on , is or was unable to work (Date) due to (Nature of illness/injury only) PROGNOSIS: Will not return to work: Will return to work on:

Address. TELEPHONE NUMBER: I, confirm that (Physician’s/Nurse Practitioner’s/▇▇▇▇▇▇▇Practitioner’s/Midwife’s name) (Please please print employee’s name) was treated by me on , is or was unable to work due to personal illness or injury as of (Nature of illness/injury only) PROGNOSIS: Will not return to work: _ Will return to work on:

Address. TELEPHONE NUMBER: I, confirm that (Physician’s/Nurse Practitioner’s/▇▇▇▇▇▇▇’s Practitioner’s/Midwife name) (Please print employee’s name) was treated by me on , is or was unable to work due to (Nature of illness/injury only) PROGNOSIS: Will not return to work: Will return to work on:

Address. TELEPHONE NUMBER: I, confirm that (Physician’s/Nurse Practitioner’s/▇▇▇▇▇▇▇’s name) (Please print employee’s name) was treated by me on , is or was unable to work (Date) due to (Nature of illness/injury only) PROGNOSIS: Will not return to work: Will return to work on:

Address. TELEPHONE NUMBER: I, confirm that (Physician’s/Nurse Practitioner’s/▇▇▇▇▇▇▇Practitioner’s/Midwife’s name) (Please please print employee’s name) was treated by me on , is or was unable to work due to personal illness or injury as of (Nature of illness/injury only) PROGNOSIS: Will not return to work: Will return to work on:

Address. TELEPHONE NUMBER: I, confirm that (Physician’s/Nurse Practitioner’s/▇▇▇▇▇▇▇’s Practitioner’s/Midwife's name) (Please print employee’s name) was treated by me on , is or was unable to work (Date) due to (Nature of illness/injury only) PROGNOSIS: Will not return to work: Will return to work on:

Address. TELEPHONE NUMBER: I, confirm that (Physician’s/Nurse Practitioner’s/▇▇▇▇▇▇▇’s name) (Please print employee’s name) was treated by me on , is or was unable to work (Date) due to (Nature of illness/injury only) PROGNOSIS: Will not return to work:

Address. TELEPHONE NUMBER: I, confirm that (Physician’s/Nurse Practitioner’s/▇▇▇▇▇▇▇Practitioner’s/Midwife’s name) (Please print employee’s name) was treated by me on , is or was unable to work (Date) due to (Nature of illness/injury only) PROGNOSIS: Will not return to work:

Address. TELEPHONE NUMBER: I, confirm that (Physician’s/Nurse Practitioner’s/▇▇▇▇▇▇▇’s name) (Please print employee’s name) was treated by me on , is or was unable to work (Date) due to (Nature of illness/injury only) PROGNOSIS: PROGNOSIS Will not return to work: