Medical certificate template

What is on the form

• Practice details, date issued and certificate number
• Patient: name, date of birth, PPS number, address, employer if disclosed, occupation
• Certification: unfit for work from and to, fit to return on, restrictions on return, review required
• First certificate, continuation or final
• Sign-off: name, qualifications and Irish Medical Council number

Using it well

• This is a certificate for an employer. Illness Benefit claims follow the Department of Social Protection's own certification process.
• Number certificates in sequence and keep a copy with the record.
• Include the employer only when the patient asks you to.