MEDICAL EXCUSE - DR NOTE

Pick a Medical Note Type

Emergency Room Visit

Urgent Care Visit

Cov19 Positive Test Results (Positive Results Only)

Primary Care Dr Letter / Medical Clearance Letter

Pet RX (Kaiser Perm. ESA Letter)

Patient First name

Patient Last name

Is the Patient a Minor?

No

Yes

Patient DOB

Which Medical Facility did you visit?

What was the general reason for the medical visit? (Optional)

Date you were admitted into care.

Date you were discharged from care

Date to return to normal activity / duty

Were you prescribed any medications during this visit?

No

Yes

Would you like to add any medical restrictions?

No

Yes

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MEDICAL EXCUSE - DR NOTE

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