Medical Statement Template

Medical statement template is a pre-constructed layout used for stating medically important lineaments concerning personal or career assertion or a patient’s health status. This kind of document has to be constructed effectively with utmost precision by carefully determining the needs.

Sample Medical Statement Template


[Specify the name of the medical authority at the letterhead by whom the particular document has to be issued]

For the purpose of _______________ [explicate the purpose of issuing the particular statement]

Date of issuing it ____________ [specify the date in dd-mm-yy format, so that track of the following document could be kept]

Doctors/ Medical Statement:

This medical statement is in confidence to Miss/ Mr /Mrs /Ms__________________________ [specify the name of the concern recipient who is being targeted in the particular document] after examining him/ her thoroughly on __________ [mention the date of examining the patient], it has been detected that the concern individual is suffering from _________________ [mention aliment that has been diagnosed] and need not have to or need to , refrain from work for about  ________________ [specify the duration till which the concern individual have to stay away from work].

However, he/ she would be subjected to medical implication following the duration mentioned above. Any further change in the health status is subjected to consideration.

Doctor’s remark: [specify if doctor has any special remark to make along with the particular document]

Signature of the Doctor: _____________ [Specify the signature in order to acknowledge the statement and impart an authentic look to the document]