Medical Clearance Letter - Provide physician clearance for concussion return to activity

Sep 16, 2026

Medical Clearance Letter template for patients who have experienced a concussion and need professional assessment before returning to work, school, or physical activities. The letter documents clinician and patient details, including dates of concussion and diagnosis, and the organization requesting clearance. It states the staged concussion management approach, emphasizes individualized recovery, and provides guidance for reverting to earlier stages if symptoms worsen. It also includes sections to specify restrictions or accommodations with details and timelines, ending with clinician signature and stamp.

LanguageEnglish

CategoryLetters

FormatPDF

Pages2

Reading Time1 min

AccessFree to download

Medical Clearance Letter

Clinician information

Patient information

Instructions and return-to-activity guidance

Restrictions and accommodations

Signature and stamp

CLEAR FORM Medical Clearance Letter | Medical Office, please complete: | | | --- | --- | | M. D. / N. P. Name | | | Medical License \# | | | Email / Contact \# | | | Date of Clearance Letter | | | M.D. / N.P. / Patient please complete: | | | --- | --- | | Date of Concussion | | | Date of Concussion Diagnosis | | | Organization/Individual Requesting Medical Clearance | | To Whom It May Concern: Patients with a concussion should be assessed and managed by a medical professional. The goal of concussion management is to support the patient’s complete recovery from concussion by promoting a safe and gradual return to activity following a staged approach. For more detailed information and resources, please refer to the Concussion Awareness Training Tool (CATT) [at](at cattonline.com)[ ](at cattonline.com)[cattonline.com](at cattonline.com). As part of the strategy, this patient had previously been instructed to avoid all activities that could potentially place them at risk of another concussion or head injury until a medical clearance letter is provided (due to organizational requirements, dangerous job duties, contact sports, etc.). This patient has explained the organizational requirements and the duties/ activities they participate in, and I have personally completed a medical clearance on this patient. Name of Patient: Note that the patient’s recovery is individual. After Stage 2, if new or worsening concussion symptoms are experienced the patient has been instructed to return to the previous stage of the strategy for 24 hours. This patient can return with full participation to work, school, or physical activities without restriction. This patient can return to work, school, or physical activities with the following restriction(s): | Restriction(s) Physical & Cognitive | Details | Timeline | | --- | --- | --- | | | | | | | | | | | | | | | | | This patient can return with full participation to work, school, or physical activities without accommodation. This patient can return to work, school, or physical activities with the following accommodation(s): | Accommodation(s) Physical & Cognitive | Details | Timeline | | --- | --- | --- | | | | | | | | | | | | | | | | | Your understanding and support are critical components in this patient’s continuing recovery. Yours Sincerely, Signature Stamp M. D / N. P. (Please circle appropriate designation)1 1 Depending upon physician or nurse practitioner access, the Medical Clearance Letter may be completed by a nurse with access to a licensed physician or nurse practitioner. Forms completed by other health care professionals (e.g., physiotherapists, chiropractors, and other allied health care professionals) should not be accepted. It is recommended that this document be provided to the patient without charge. © BCIRPU 2019. All rights reserved. Version 1: Updated May 2019. Adapted with permission from Parachute Canada’s Medical Clearance Letter. Page 2 of 2

FAQs

What is the purpose of this medical clearance letter for concussion?

It documents that a patient with a concussion has been assessed and can return to activity under the letter’s specified conditions, supporting safe and gradual recovery.

What information must be completed by the medical office and the patient?

The medical office provides clinician identification and contact details, and the patient provides dates of concussion and diagnosis plus the party requesting medical clearance.

How should the patient respond if concussion symptoms worsen after Stage 2?

If new or worsening symptoms occur after Stage 2, the patient should return to the previous stage of the strategy for 24 hours.

How are work, school, or physical activity limits recorded in the letter?

The letter includes sections for restrictions and for accommodations, each with details and a timeline, or it may indicate full participation without restrictions.

Sep 16, 2026

Upload by Lucas Martin