Family Practice Physicians Dr. C.J. Wilson Jr., M.D. Dr. J. Burrough, M.D. Dr. Levingston

Family Practice Physicians
Dr. C.J. Wilson Jr., M.D.
Dr. J. Burrough, M.D.
Dr. Levingston, M.D.
Dr. Patrick Wilson, D.O.
Dr. Matthew McOwen, D.O. /
Fairfew Family Family Practice Physicians
555 Lindsore Ave, Dallas TX Suite 23
PH: 555.555.5555 | FX:555.555.5555
“ / Additional Staff
Mark Kerry, Nurse Practitioner
Kerry Marquis, LPN
Judith Marymore, CNA
Sarah Wilkens, RN
Jasmine Keifer, RN
TO WHOM IT MAY CONCERN:
THIS IS TO CERTIFY THAT
Mr./Mrs.______was
absent from work / school from ______to ______as a result of medical
complications. Please carefully review the medical restrictions
below.

*** MEDICAL RESTRICTIONS ***

r  Light duty (no water or solvent exposure) / r  Limit walking – no more than ____ feet per hour. / r  No lifting whatsoever.
r  Sitting work only – no walking or prolonged standing / r  Limit arm use, not to lift over five lb. with injured arm. / r  Light lifting only – no more than 20 lbs.
Stamp of Medical Practitioner (optional)
/ PLEASE REVIST OUR OFFICES FOR A RE-EVALUATION ON ______, 20_____.
Sincerely,

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