Doctor’s Note

Doctor’s Name: Dr.

Address:

City, State, Zip Code:

Phone Number:

Date:

Please Excuse:

From: (indicate check mark)

-‐ Work
-‐ Other
_____________________________________

Due To:
-‐ Injury
-‐ Illness
-‐ Other
____________________________________

For the following dates:

from to
Dr. ______________