UPSTATE

UNIVERSITY HOSPITAL

CENTER

Department of Medicine Firm B

UNIVERSITY HEALTH CARE

90 Presidential Plaza, Syracuse, NY 13202

Date:__________________
Patient Name:________________________________________
MR#:________________________________________________
DOB:___________ Age:_________ Gender:________________
The following individual, _______________________________, was treated in our
offices for
____________________________________________________________________________
____________________________________________________________________________
_______________. They may return back to work/school on ______________ with
/ without restrictions.

____________________________________________
Provider's Signature

______________________________________________________________________________________________
_______
F82312- Excuse Rpt
Rev.7/2011

CAIS

MR