Doctor’s Excuse 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. ______________