Doctor’s Note 

Doctor’s Name: Dr. _____________________ 
Address: _______________________________
City, State, Zip Code:_______________________ Phone_______________ Number: ___________

Date: _______________________________________
 
Please Excuse:_____________________________________________________________________________________________ 
 
From:  
☐ -­‐ Work 
☐ -­‐ Other_______________________________________________________________________________________________ 
 
Due To: 
☐ -­‐ Injury 
☐ -­‐ Illness 
☐ -­‐ Other_________________________________________________________________________________________________ 
 
For the following dates: 
 
________________________ to_____________________________________ 

Regards, ____________________________________________________ 

Dr. ______________