Common use of Address Clause in Contracts

Address. TELEPHONE NUMBER: I, confirm that (Physician’s/Nurse 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/MidwifeXxxxxxx’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/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/Midwife’s name) (Please 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/Midwife’s name) (Please 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:: _ (Date)

Address. TELEPHONE NUMBER: I, confirm that (Physician’s/Nurse Practitioner’s/Midwife’s name) (Please please print employee’s name) was treated by me on , is or was unable to work (Date) 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/Midwife’s Midwife 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’spractitioner’s/Midwife’s nameName) (Please 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/Midwife’s name) (Please please print employee’s name) was treated by me on , is or was unable to work (Date) 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/Midwife’s name) (Please 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/MidwifeXxxxxxx’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: Will return to work on:

Address. TELEPHONE NUMBER: I, confirm that (Physician’s/Nurse Practitioner’s/Midwife’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: