Medical Absence Form

In cases where an employee will go on leave, a manager may request the employee to provide a medical certificate from the treating medical practitioner to confirm that the absence is due to illness or injury. Below is an example that could be used as a medical certificate.

Consult the guide for Obtaining Information for Health Care Practitioners in Cases of Employee Illness or Injury for more information on when and how to use this form.

The purpose of this form is to enable the patient to provide his /her employer with confirmation that his/her absence from work is due to illness or injury.

Completion of this form is an uninsured medical service. In accordance with the language of existing collective agreements, any fee associated with its completion is the responsibility of the patient.

Note to Physicians:

  1. This form is not intended for work-related illnesses or injuries. For a work-related illness or injury, please complete the required provincial workers' compensation board physician's report. View list of provincial and territorial workers' compensation boards.
  2. Please do not include any information about the employee's diagnosis, or details about the employee's treatment (including medication).
  3. Please provide a copy of this form to the patient, and keep a copy for your records.

Physician's Name:



I saw (Please print patient's name) on (dd/mm/yyyy) .

Given the health information before me:

  • I am satisfied that, due to illness or injury, this patient did not / will not attend work, starting on (dd/mm/yyyy).
  • This patient returned / will return to work on .(dd/mm/yyyy)
  • This patient needs further medical assessment before returning to work.

Date of next appointment (dd/mm/yyyy).

Physician's Signature:


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