Thank you. Your Health is Important to Us.

Please be reminded this form is desigined for patients who had to miss or cancel their flight, cruise, or hotel reservations due to having a acute illness.

Thank you. Your Health is Important to Us.

Please be reminded this form is desigined for patients who had to miss or cancel their flight, cruise, or hotel reservations due to having a acute illness.

If you are currently experiencing severe symptoms that require prompt medical attention in the Emergency Room we recommend you go to the Emergency Room.

If your airline or travel insurance does not allow for telemedicine to be used for obtaining a doctor's excuse note, please be seen by a local in-person provider.

It looks like you are qualified to use our service

In this next section, we will need you to share with us more details about your medical condition. Please note, the symptoms and medical condition you share with us will not be included in the note due to HIPAA regulations. 

Please be advised that most airlines or travel insurance companies may require an additional Physician Statement form to be completed. If needed, this can be completed for no additional charge. If you already have this particular form available you will be prompted to upload this on the next page.  

For Travel cancellation notes it is required to have a selfie video examination component. On the next page you will be prompted to upload a short 30-60 second video. State your name and a brief summary of your current symptoms that require you to cancel your travel. The provider assigned to your request will review this video examination as part of the approval process. Click "next" to proceed. 

If using your smartphone, you will be prompted to "take a new video". Be sure your camera is flipped around to selfie mode to complete the video and then you can upload that file. 

Thank you. In this next section, we will need you to enter your personal information such as your name, DOB, address, phone number, and email address.

We will also need you to take a selfie and a picture of your photo ID for identity verification.

The only personal information that will be included in your note will be your name and DOB.

Please be informed, we operate under strict HIPAA regulations. This means, all of the other personal identification information you provide us will be kept confidential and secure using the highest HIPAA compliant standards, and will not be shared.

Please verify that your information below is correct. This is how it will appear on the note. If you need to make corrections, please click the "previous" button and go back to edit that information. 

Name: {ltstronggtfirstNameltstronggt} {ltstronggtlastNameltstronggt}

Date of Birth: {ltstronggtdateOf}

We will now need you to take a couple of photos for identity verification.

Why do we need a selfie and photo ID?

• A selfie and photo ID match is essential for fraud prevention. It helps to insure that you are actually the person requesting the doctor's note and are authorized to use the payment method detailed on the next page.
• 
  If you prefer, feel free to cover the license or passport number for added privacy. However, please make sure the photo ID clearly shows your name and date of birth so it can be matched to the information you already provided. 

Your information will be kept confidential and secure using HIPAA compliant standards and will not be shared. Your privacy is our utmost concern.

Thank you for submitting all the information necessary for request to be reviewed. 

If approved you will be recieving a signed note from one of our Board-Certified Physicians. Most requests are reviewed within one hour. If you have not heard about the request decision within 1 hour then please reach out to us at contact@mydrsnote.com.

Your confirmation email will be from this email address. Be sure to check your spam folder if you do not see it in your inbox. 

Please be reminded, there are no refunds once you receive our note as a secure (password protected) attachment in your email.

General recommendations to help you recover from your mild illness includes:

• Staying well hydrated with plenty of water intake
• Getting plenty of rest
• Taking over the counter medications as appropriate
• Sticking to a clean simple diet high in antioxidants from naturally grown foods
• Taking medications as prescribed by your medical provider

To obtain your authentic doctor's travel cancellation note signed by one of our Board-certified licensed physicians, please proceed to the last page to submit your payment. We have partnered with Stripe to securely process your payment. You will only be charged if the requst is approved. Thank you.