Instructions
In order to most efficiently process your form(s), please digitally fill them out and submit electronically via email. For detailed instructions, please see steps 1-4 below.
01
Download
Please SCROLL DOWN to download the necessary form(s) from the list below
02
Open
Open the file (.pdf) with Adobe Acrobat Reader
To download Adobe Acrobat Reader: get.adobe.com/reader
03
Fill & Sign
Fill out required information and sign the form (if needed)
It is very important to FILL IN ALL INFORMATION before submitting the form.
Form List
- Clinic notes and radiology/operative reports should be obtained through Patient Gateway or by request to medical records.
- Patient Gateway: https://www.brighamandwomens.org/patients-and-families/patients/using-patient-gateway
- Medical Records: 617-732-6071
Don’t see your form in the list below?
Dr. Dyer’s office provides this complimentary form to address patient work status and restrictions.
If you have additional forms to be completed, you may request we fill out your form(s) via email (patientforms@georgedyerortho.com) at the cost of $25 per each additional form.
US Department of Labor – Family and Medical Leave Act Form
Massachusetts Department of Family and Medical Leave – Certification of a Serious Health Condition Form
Unum – Massachusetts Paid Family Medical Leave Request Form
Unum Short Term Disability Claim Form
BWH Employee’s Serious Health Condition Certification Form
MGB / Partners Healthcare Work Status Form
MGB / Partners Healthcare Return to Work Clearance Form
Additional Forms
If you have additional forms to be completed, you may request we fill out your form(s) via email (patientforms@georgedyerortho.com) at the cost of $25 per each additional form.