Note for your health care provider
A printable from Pregnancy and Pumping at Work. Fill it in by hand. Nothing you write is collected by this website.
Note for your health care provider
Please write a short note on your letterhead that says:
- My patient, ______________, has a condition related to pregnancy / childbirth / lactation.
- Because of it, they need this change at work: ______________
- Starting ______________ and lasting about ______________.
- Your name, title, signature, date and phone number.
The note does not need to include a diagnosis or medical history.
From Pregnancy and Pumping at Work. Facts checked October 21, 2026. Free information, not legal or medical advice.