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Return to work, school, daycare

An eform for a return to work, school or daycare note. Contributed by Jel Coward.

HTML icon — HTML, 3 kB (3215 bytes)

File contents

<!DOCTYPE HTML PUBLIC "-//W3C//DTD HTML 4.0 Transitional//EN">
<html>
<head>
  <meta http-equiv="CONTENT-TYPE"
 content="text/html; charset=windows-1252">
  <title>return to work</title>

   <style>
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		P { margin-bottom: 0.08in; direction: ltr; color: #000000; widows: 2; orphans: 2 }
		
		p.small { margin-right: 0.5in; margin-left: 0.5in; font-family: "Times New Roman", serif; 
		font-size: 10pt  }
		
		p.bold { margin-bottom: 0.08in; direction: ltr; color: #000000; widows: 2; orphans: 2; font-weight:bold }


		H1 { font-family: "Times New Roman", serif; font-size:24pt; text-align: center }

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		textarea { overflow: hidden;  border-width: 0;  font-family: "Times New Roman", serif; font-size: 12pt }
		
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	-->
	</style>

<style media="print">
.hide {
display:none }
</style>
</head>
<body>

<p  align="center" style="border-style: double none none; border-color: rgb(0, 0, 0) -moz-use-text-color -moz-use-text-color; border-width: 1.1pt medium medium; padding: 0.02in 0in 0in; margin-bottom: 0in;"></p>

<H1>Pemberton Medical Clinic</H1>

<p  align="center" style="border-style: double none none; border-color: rgb(0, 0, 0) -moz-use-text-color -moz-use-text-color; border-width: 1.1pt medium medium; padding: 0.02in 0in 0in; margin-bottom: 0in;"></p>
<br>

<form name="form1" method="post" action="">


<table class="head">
  <tr>
    <td width="50%" valign="top">

<input type="checkbox" name="C1" value="ON">Dr. Hugh Fisher 03877<br>
<input type="checkbox" name="C2" value="ON">Dr. Rebecca Lindley 26399<br>
<input type="checkbox" name="C3" value="ON">Dr. Marisa Collins 07067<br>
<input type="checkbox" name="C4" value="ON">Dr. Jel Coward 27015
</td>
    <td width="50%" valign="top" align="right">Box 69, Pemberton, B.C. V0N 2L0 <br>
Phone 604-894-6454<br>
      Fax
604-894-6721
</td>
  </tr>
</table>

<br>
<p>
<input type="text" name="date" size="20" oscarDB=Today class=noborder>
</p>
<br>






<P>To whom it may concern:</P>

<br>
<br>

<P></P>
<input type="text" name="name" type="text" size="20" oscarDB=patient_name class=noborder>
is fit to return to work &nbsp; / &nbsp; school &nbsp; / &nbsp; daycare
</p>

<p>
<textarea name=reason cols="50" rows="12"></textarea>
</p>

<p class="bold"> 
Signed:</p>

<br>
<br>

<p class="hide">
 <input type="submit"
 value="Submit" name="B1" class="button">
 <input type="button" value="Print" onclick="javascript:window.print()"  class="button"> <br>
  <input type="button" value="Close Window"
 onclick="javascript:self.close();"
 onkeypress="javascript:self.close();" class="button"></p>
 </form>
</body>
</html>
            

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