Note request

1
What do you need a doctor's note for?* This field is required.
Work
School
2
What is your email?* This field is required.This is where we will send the note
Email
Confirm Email
3
What is your full name?* This field is required.
4
What is your date of birth?* This field is required.
Date
Mois
Jour
Année
5
Select your reason for absence* This field is required.Choose the option that best describes your medical situation
Common Cold/Flu
Stomach Bug
Sore/Strep Throat
COVID-19 Symptoms/Exposure
Headache/Migraine
Mental Health Condition
Injury
Taking Care of Family Member
Medical Appointment
Other
6
Select your current symptoms* This field is required.Select all symptoms which you have
Runny Nose
Cough
Sore Throat
Chest Congestion
Fatigue/Weakness
Fever
Chills/Sweats
Sneezing
Headache
Body Aches/Muscle Pain
Nausea
Other
7
Making sure online care is the right choice for you* This field is required.Please confirm you are NOT experiencing any emergency symptoms: ִ● Severe chest pain or difficulty breathing ● Severe abdominal pain ● High fever over 103°F (39.4°C) ● Severe headache with neck stiffness ● Sudden vision changes or confusion ● Severe dizziness or fainting If yes, please seek immediate medical attention by visiting your nearest emergency room or calling 911
I am NOT Experiencing Any Emergency Symptoms
8
Important: Uplydoc Cannot support absences for:* This field is required.● Work Restrictions or Accommodations ִ● Insurance Claims ִ● Disability or FMLA Documentation ִ● Workman's Compensation ִ● Court Appearances ִ● Probation Check-Ins ִ● Drug Tests ִ● Military Duty
I have read and understand the above limitations.
9
What is your zip code?We'll make sure your note meets local requirements
10
Date
Date
Mois
Jour
Année
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Heure
44
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Minutes
11
What is the first day you will be absent?* This field is required. Due to Telehealth limitations, we are required to limit doctor's note requests to 7 days of absence within any 30-day period.
Mois
Jour
Année
12
What date will you return to work?* This field is required.Due to Telehealth limitations, we are required to limit doctor's note requests to 7 days of absence within any 30-day period.
Mois
Jour
Année
13
What state are you in?* This field is required.We'll match you to a doctor licensed in your state.
Alabama
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Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
14
Terms and Conditions* This field is required.
15
Thank you! You are almost there.* This field is required.🔒 Secure your spot with one of our doctors by checking out on the next page. 🗒️ We'll match you to a licensed doctor in your state. ⏱️ Receive your doctor’s notes within 10 minutes.
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