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Physician’s Treatment Memorandum
Last Name: _______________________________________________________
Given Names: _____________________________________________________
The above employee has reported to have been injured in our employ on _______
20___ and may require medical aid.
(Name of Property)
12345 - 67 Street
Anywhere, Alberta
T0Y 0K0
Telephone : 555-1212
Fax: 555-2121
Supervisor:_________________________________________________________
Doctor:
If it appears this employee will be disabled from earning full wages on any day
beyond the day of incident, please submit a Doctor’s first report to the Workers’
Compensation Board. Providing information and returning it to the Hotel will assist
us in planning for this employee’s rehabilitation and maintaining their income.
Doctor’s advice to Supervisor:
1.
Employee may return to their job today. ____
2.
Employee may return to their job for the next shift.____
3.
Employee may return to next shift with modified duties. (List
modifications)
_______________________________________________________
_______________________________________________________
_______________________________________________________
4.
Employee will be absent for ______ working days.
Doctor’s Signature:
_________________________________________________________________
Date: ____________________________________________________________
Telephone: ________________________________________________________