Ronald Reagan UCLA Medical Center

757 Westwood Plaza

Los Angeles, CA 90095
310-825-9111
Date: ____/____/______
Please Excuse:
______________________________________________
From:
[__] Work
[__] Class
[__] Other________________________________________________
Due To:
[__] Injury
[__] Illness
[__] Other________________________________________________
For the following dates:
____/____/______ - ____/____/______

Thank You,
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