Dentist Excuse Form

1
Date of visitEX: 4/09/2024
2
Full name of patient
First Name
Last Name
3
Return back date EX: 4/10/2024
4
Patient arrival time EX: 1:00PM
5
Patient release time EX: 5:00PM
6
Your zip code EX: 87705
7
Would you like your order expedited?
No
Yes, Expedite for $50
8
Payment Options are Cash app, Apple Pay, Zelle or Chime. Please reach out for chime information or Apple Pay number
9
Have you submitted payment?*all orders go in the order of payment received* *please be aware there may be orders before yours*
YESNO
10
Please submit proof of payment *screenshot*
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11
EmailDocument will be sent to your email in PDF
example@example.com
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Dentist Excuse Form