Excuse note Form

1

Which note do you need?

Regular excuse note $35

Custom excuse note $60

2

Please skip the next TWO questions if you chose regular excuse note. DO NOT ANSWER THE NEXT TWO QUESTIONS UNLESS YOU ARE GETTING A CUSTOM NOTE. Do you understand?

YESNO

3

What is the preferred doctor full name and full office address?

4

Please type EXACTLY what you want written on the custom letter, EXACTLY how you want it. *THIS IS FOR CUSTOM EXCUSE NOTE ONLY, SKIP IF YOU CHOSE REGULAR EXCUSE NOTE*

5

Patient full nameEX: Mary Jane Doe

6

DOBEX: November 19, 1990

7

Return to work or school?

School

Work

8

Date of visitEX: January 20, 2025

9

Return Date to work/school dateEX: January 22, 2025

10

Your zip codeEX: 77301

11

Would you like your order expedited?*Expedite will prioritize your order and put you ahead of everyone else*

No, I’ll wait

Yes please expedite for $50 EXTRA ($50 is ADDED to your total)

12

Payment Options are Apple Pay, Cash App or Chime. Please reach out for cash app information. How will you be paying?

Chime $therealanac

Apple Pay 713-429-2513

Cash app

Other

13

Have you submitted payment? *all orders go in the order of payment received* *please be aware there may be orders before yours, unless you chose to expedite*

YESNO

14

Email

example@example.com