Common use of PHYSICIAN’S SECTION Clause in Contracts

PHYSICIAN’S SECTION. TO THE PHYSICIAN: Your patient is a teacher with the Chignecto-Central Regional School Board. The teacher has been absent from work due to illness since The Board requires information regarding the teacher’s current medical condition. Please complete this form only if you have treated the teacher during the illness in question, or have predetermined medical information that this individual has been ill since that date specified above. Your cooperation is appreciated. The teacher will require a receipt for any fee charged for obtaining this medical information. (1) Teacher’s Name: (2) Teacher’s Address: (3) Date(s) you attended the teacher: (4) Duration of current illness or injury: From To (5) Expected date of return to regular duties of work: (6) Has the patient’s current illness prevented him/her from reporting for and performing his/her job? Yes No (7) On the patient’s return to work are there restrictions on any activities the employee can engage in? (8) Physician’s Name and Address: Physician’s Signature Date Other remarks (use additional sheet if necessary)

PHYSICIAN’S SECTION. TO THE PHYSICIAN: Your patient is a teacher with the Chignecto-Central Regional School Board. The teacher has been absent from work due to illness since . The Board requires information regarding the teacher’s 's current medical condition. Please complete this form only if you have treated the teacher during the illness in question, or have predetermined medical information that this individual has been ill since that date specified above. Your cooperation is appreciated. The teacher will require a receipt for any fee charged for obtaining this medical information. (1) Teacher’s 's Name: (2) Teacher’s 's Address: (3) Date(s) you attended the teacher: (4) Duration of current illness or injury: From To (5) Expected date of return to regular duties of work: (6) Has the patient’s current illness prevented him/her from reporting for and performing his/her job? Yes No (7) On the patient’s return to work are there restrictions on any activities the employee can engage in? (8) Physician’s 's Name and Address: Physician’s 's Signature Date Other remarks (use additional sheet if necessary)Date

PHYSICIAN’S SECTION. TO THE PHYSICIAN: Your patient is a teacher with the Chignecto-Central Strait Regional School Board. The teacher has been absent from work due to illness since __________________________ The Board requires information regarding the teacher’s current medical condition. Please complete this form only if you have treated the teacher during the illness in question, or have predetermined medical information that this individual has been ill since that date specified above. Your cooperation is appreciated. The teacher will require a receipt for any Any fee charged for obtaining applicable to your completing this medical information. (1) Teacher’s form should be billed directly to the Strait Regional School Board. Teachers Name: (2) Teacher’s : Teachers Address: (3) : Date(s) you attended the teacher: (4) : Duration of current illness or injury: From To (5) __________________ to _______________ Expected date of return to regular duties of work: (6) : _______________________________ Has the patient’s current illness prevented him/her from reporting for and performing his/her job? Yes No (7) ____________ No ______________ On the patient’s return to work are there restrictions on any other types of activities the employee can engage in? (8) ? Physician’s Name and Address: Physician’s Signature Date Other remarks (use additional sheet if necessary)