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16
Questions
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1
Which note do you need?
Regular excuse note $35
Custom excuse note $60
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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?
YES
NO
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3
What is the preferred doctor full name and full office address?
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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*
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5
Patient full name
EX: Mary Jane Doe
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6
DOB
EX: November 19, 1990
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7
Return to work or school?
School
Work
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8
Date of visit
EX: January 20, 2025
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9
Return Date / release date
EX: January 22, 2025
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10
Date the excuse note was WRITTEN
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11
Your zip code
EX: 77316
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12
Would you like your order expedited?
*Expedite will prioritize your order and put you ahead of everyone else*
No, I’ll wait my turn
Yes please expires for $50 EXTRA ($50 is ADDED to your total)
Type option 3
Type option 4
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13
Payment Options are Apple Pay, Chime or cash app. Please reach out for cash app information. How will you be paying?
Chime $therealanac
Cash app
Apple Pay 713-429-2513
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14
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*
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NO
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15
Please submit proof of payment *IF YOU DO NOT PAY, YOU ORDER WILL NOT BE STARTED ON!, I will NOT proceed without payment* (Screenshot)
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: 10.6MB
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16
Email
example@example.com
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Excuse note Form
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