Free Doctors Excuse Note PDF Form

DOCTOR’S EXCUSE NOTE

Institution: ____________________________________________

Dr. ___________________________________________________

Address: ______________________________________________

Phone: ________________________________________________

Email: ________________________________________________

Date of examination: _______________, 20_____

Return appointment: _______________, 20_____

That is to certify that patient __________________________________ was under my care at my

office on _______________, 20_____. Please excuse this absence.

Health issue description:

______________________________________________________________________________

______________________________________________________________________________

______________________________________________________________________________

______________________________________________________________________________

______________________________________________________________________________

EXAMINATION RESULT

□Full Duty: may return to work\school without any restrictions or limitations.

□Light Duty: may return to work\school with restrictions and\or limitations (described below). Restrictions duration: _____________; Limitations duration: _____________;

□Off Work: patient cannot return to work\school and is not able to perform their duties until _______________, 20_____ or until next evaluation.

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RESTRICTIONS (if applicable)

□Other:

______________________________________________________________________________

______________________________________________________________________________

______________________________________________________________________________

LIMITATIONS (if applicable)

□Working\Studying hours per day allowed: ____ hours.

□Must take at least ____ breaks during the working\studying day.

□Minimum break duration: ____ minutes.

□Must wear a brace

□Other:

______________________________________________________________________________

______________________________________________________________________________

______________________________________________________________________________

Additional Doctor’s Comments:

______________________________________________________________________________

______________________________________________________________________________

______________________________________________________________________________

______________________________________________________________________________

______________________________________________________________________________

______________________________

(doctor's signature)

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