Note to Employee: This form must be returned to your supervisor immediately following your medical appointment
TOWN OF LOS GATOS MEDICAL REFERRAL FORM
TO BE COMPLETED BY SUPERVISOR / MANAGER
Employee:
Department:
Date Injured:
Title:
Supervisor:
Date Sent to Doctor:
TO BE COMPLETED BY ATTENDING PHYSICIAN
and returned with employee
Please consider the availability of modified work when considering estimated periods of disability.
Date of Examination: Time In: Time Out:
WORK STATUS:
Regular work effective:
Temporary modified work, effective:
until:
(Outline Work Limitations Below)
Temporarily Totally Disabled, unable to perform any work until:
Please specify what precludes a return to work in a modified or limited hours capacity:
Anticipated Date of Return to Full Duty: ___________________________________________
WORK LIMITATIONS: Check all functional limitations and outline frequency limitation.
No prolonged walking/standing Limited walking/standing hrs/min interval
No repetitive bending/stooping No kneeling or squatting
No climbing of stairs or ladders Limited sitting hrs/min interval
No pushing or pulling No lifting over lbs
No reaching above shoulder No operation/work around moving machinery.
No Driving. Avoid exposure to extreme heat or cold
Keep bandages clean and dry
Limited/No use of:
Other:
DISPOSITION:
Future care recommended, no permanent disability anticipated
Future care recommended, permanent disability unknown or anticipated
Discharged, no permanent disability anticipated
Discharged, permanent disability anticipated; anticipated permanent and stationary date:
Physical Therapy Yes No _____ / _____(times/week), or M T W TH F (circle one)
Referred to Doctor: Date:
For: Authorized by:
Physician's name: Signature:
Phone:___________________________
Send Doctor's First Report To: LWP Claims Solutions, P. O. Box 349016
Sacramento, CA 95834-9016 (800) 565-5694 FAX (408) 725-0395
Fax Copy to:Town of Los Gatos (408) 395-8640
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