Free template
Doctor’s Injury Certification Template
Provide a clear medical injury certification summarizing diagnosis, treatment, and temporary or ongoing limitations.
Downloaded 4157 times
Download template
Doctor’s Injury Certification Template
[Clinic / Practice Name]
[Street Address]
[City, State/Province, ZIP/Postal Code]
Phone: [Phone Number]
Fax: [Fax Number]
Email: [Email Address]
1. Patient Identification
Patient Full Name: [First, Middle, Last]
Date of Birth: [MM/DD/YYYY]
Age: [Age]
Gender: [Gender]
Patient ID / Chart Number (if applicable): [ID Number]
Home Address:
[Street Address]
[City, State/Province, ZIP/Postal Code]
Phone Number: [Phone Number]
Email Address: [Email Address]
2. Evaluating Provider Information
Provider Full Name: [Name]
Professional Title and Credentials: [e.g., MD, DO, NP, PA]
Specialty: [e.g., Emergency Medicine, Orthopedics, Family Medicine]
License Number: [Number]
Licensing State/Province: [State/Province]
Practice / Facility Name: [Name]
Address: [Street Address, City, State/Province, ZIP/Postal Code]
Phone: [Phone Number]
Fax: [Fax Number]
3. Examination Details
Date of Examination: [MM/DD/YYYY]
Time of Examination (if relevant): [HH:MM a.m./p.m.]
Location of Examination: [Clinic / Hospital / Emergency Department / Other]
Evaluation Type:
Initial Evaluation
Follow-Up Evaluation
This certification is being completed for (check all that apply):
Work / Employer
School / University
Insurance
Legal / Court
Other: [Describe]
4. Injury Incident Summary (As Reported by Patient)
Date of Injury: [MM/DD/YYYY]
Approximate Time of Injury: [HH:MM a.m./p.m., if known]
Location of Injury: [Workplace, home, street, school, sports facility, etc.]
Brief Description of Incident (patient’s report):
[Free-text narrative, e.g., “Patient reports that on [date], while [activity], they…”]
Note: The above description is based on the patient’s statements and is not an independent investigation of the incident.
5. Diagnosis and Injured Body Area(s)
Primary Injury Diagnosis:
[Diagnosis name and, if desired, ICD-10 code]
Additional Injury Diagnoses (if applicable):
[Diagnosis 2]
[Diagnosis 3]
Body Part(s) Affected:
[e.g., “Left ankle,” “Right shoulder,” “Lumbar spine,” “Head,” etc.]
Injury Type (check or describe):
Contusion / Bruise
Laceration / Cut
Sprain / Strain
Fracture / Suspected Fracture
Concussion / Head Injury
Soft Tissue Injury
Other: [Describe]
6. Clinical Findings and Tests
Physical Examination Findings (summary):
[Brief description, e.g., “Swelling and tenderness over…,” “Reduced range of motion…,” “Neurological exam normal/abnormal,” etc.]
Imaging / Tests Performed (if any):
X-ray – Date: [Date] – Results: [Summary]
CT Scan – Date: [Date] – Results: [Summary]
MRI – Date: [Date] – Results: [Summary]
Ultrasound – Date: [Date] – Results: [Summary]
Laboratory Tests – [Type and brief results]
Other: [Describe]
Summary of Objective Findings:
[Short, clear statement summarizing key findings relevant to the injury.]
7. Treatment Provided and Current Plan
Treatment Provided to Date (check or describe):
Wound care / suturing / dressing
Splint / cast / brace applied
Pain management (medication)
Anti-inflammatory medication
Physical therapy referral
Specialist referral (e.g., orthopedic, neurology)
Hospital admission
Other: [Describe]
Current Treatment Plan and Recommendations:
[Brief description, e.g., “Continue wearing brace,” “Begin physical therapy 2 times per week,” “Follow-up visit in 2 weeks,” etc.]
8. Functional Limitations and Activity Restrictions
Based on my clinical evaluation as of [Date], the patient has the following limitations and restrictions:
Work / School Status:
May work / attend school with no restrictions as of [Date].
May work / attend school with restrictions as outlined below.
Temporarily unable to work / attend school from [Start Date] to [Estimated End Date].
Unable to determine work/school capacity at this time; further evaluation needed.
Activity Restrictions (check all that apply and specify if needed):
No lifting over [] lbs / [] kg.
No prolonged standing or walking (limit to [___] minutes at a time).
No running, jumping, or high-impact activities.
No bending, twisting, or heavy pushing/pulling.
No climbing ladders or working at heights.
No driving or operating heavy machinery until [Date] or until cleared.
Seated work only, with the ability to change positions as needed.
Limited use of [right/left] arm / leg.
Other restrictions: [Describe].
Expected Duration of Restrictions (subject to change with recovery):
Less than 1 week
1–4 weeks
4–8 weeks
More than 8 weeks
To be determined at next follow-up
9. Prognosis
Overall Prognosis for Recovery from This Injury:
Good (full recovery expected)
Fair (recovery expected, may have some residual symptoms)
Guarded (uncertain outcome; may have ongoing limitations)
Poor (significant long-term or permanent limitations likely)
Comments on Expected Recovery:
[Brief narrative about anticipated improvement, need for ongoing care, or potential long-term effects.]
10. Additional Comments (Optional)
[Space for the provider to add any clarifying information regarding the injury, limitations, or special considerations. Avoid legal opinions or statements about fault.]
11. Provider Certification
I, [Provider Full Name], certify that I am a licensed healthcare provider and that the above information is accurate to the best of my knowledge, based on my examination of the patient and available medical records as of the date of this certification.
This certification is intended to describe the patient’s medical condition, treatment, and functional limitations. It is not a determination of legal liability or entitlement to benefits. Decisions regarding work status, accommodations, benefits, and legal issues are made by the appropriate employer, agency, insurer, or authority.
Provider Signature: _______________________________
Printed Name: [Provider Full Name, Credentials]
Date: [MM/DD/YYYY]
Optional Stamp or Seal:
[Space for provider or clinic stamp]
Flash deal
Flash deal
Today
Today
No time to fill it up? Generate your custom agreement with AI Lawyer in seconds
What’s Included
Legal Research
Legal Research
Legal Research
Contract Drafting
Contract Drafting
Contract Drafting
Document Review
Document Review
Document Review
Risk Analytics
Risk Analytics
Risk Analytics
Citation Verification
Citation Verification
Citation Verification
Easy-to-understand jargon
Easy-to-understand jargon
Easy-to-understand jargon
Details
Learn more about
Doctor’s Injury Certification Template
Click below for detailed info on the template.
For quick answers, scroll below to see the FAQ.
Click below for detailed info on the template.
For quick answers, scroll below to see the FAQ.
DOCTOR’S INJURY CERTIFICATION TEMPLATE FAQ
What is a Doctor’s Injury Certification?
A Doctor’s Injury Certification is a written statement from a licensed healthcare provider confirming that a patient has sustained a specific injury, describing the nature of that injury, treatment provided, and any temporary or ongoing limitations. It is often requested by employers, schools, insurance companies, attorneys, or courts.
When is a Doctor’s Injury Certification used?
This type of certification may be used after motor vehicle accidents, workplace injuries, sports or recreational injuries, falls, assaults, or other incidents that cause physical harm. It can support medical leave requests, workplace accommodations, school excuses, insurance claims, or documentation in a legal case.
What should be included in a Doctor’s Injury Certification?
A useful Doctor’s Injury Certification typically includes: patient identification, provider’s name and credentials, date of examination, brief description of the incident (as reported by the patient), diagnosis and affected body parts, summary of treatment, functional limitations and restrictions (for work, school, or activities), expected recovery time, and follow-up recommendations. It should clearly state what the doctor can and cannot certify.
Does a Doctor’s Injury Certification determine legal fault or liability?
No. A Doctor’s Injury Certification is a medical document focused on diagnosis, treatment, and functional impact. It does not assign legal fault for the incident or determine liability. Legal responsibility is decided by courts, insurers, or other authorities based on all available evidence, not by the treating provider alone.
How detailed should a Doctor’s Injury Certification be?
The certification should be specific enough to be useful, but focused on medical facts and professional opinion. It should avoid speculation about events the provider did not witness and should keep sensitive personal information to what is reasonably necessary for the stated purpose (work, school, insurance, or legal).
Can AI Lawyer help me prepare a Doctor’s Injury Certification?
Yes. AI Lawyer can help format and organize a Doctor’s Injury Certification by suggesting clear sections and wording. However, only a licensed healthcare provider should complete the medical details, clinical opinions, and signature. This template and any AI-generated text are for document organization only and are not medical or legal advice. For case-specific questions, consult a licensed physician and attorney.
Similar templates
Other templates from
Employment Legal Templates
Money back guarantee
Free trial
Cancel anytime
AI Lawyer protects
your rights and wallet
Money back guarantee
Free trial
Cancel anytime
AI Lawyer protects
your rights and wallet
Money back guarantee
Free trial
Cancel anytime
AI Lawyer protects
your rights and wallet
Money back guarantee
Free trial
Cancel anytime