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. ______________