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Medical Leave Form - India

Wil the employee need leaveAime off wofk for a síngle continuous period of time due to his/her
medical condition, including time for treatment and recoveryn WYes ONo

If yes,estimate the begin and end date for the period of leave/time off vwork required
through
Start date End date

Additional Information (if any):

UHealth Care Provider Name:

-EALTH CARE OSpecialty/Type of Practice:

-ROVIDER
iNFORMATION D Clinic or Hospital Name: (AREWEL SurersfeqALIry tasfrn
(To be completed Address:
by health care
provider)
City: UNTUR PIN Code: S220o
OPhone No:
834|9133 Fax No.:

Icertify that the

information on this form is accurate and truthful tothe best of my
knowledge.

Signáture of Health Care Provider and Stamp

Dr. SHAIK NAGOOR BASHA Date
Regd.No: O97
MOGen.Med).DMHOSPITAL
CAREWELL SUPERSPECIALITY (Gtro)
Opp. Bus $tend, Boalde enOl
7th Line,Gr Ven Potrol Puop Line,
Thotu, GUNTUR-522 001, A.P