Request a Work Excuse Note (Telemedicine)

Full Name

First NameLast Name

What medication allergies do you have? Enter NONE if you do not have any.

What medical conditions do you have?

Date of Birth

Date

Phone Number

Please enter a valid phone number.Format: (000) 000-0000.

Email Address

example@example.com

State

Preferred Contact Method

Date(s) to Be Excused From Work From

Date

To

Date

What type of illness is this?

Details for Work Note Request (briefly describe your symptoms or situation)

Employer Name (optional)

Employer Contact Information (optional)

I consent to receive healthcare services via telemedicine, understand the nature and limitations of virtual care (including potential technology risks), and acknowledge that I may withdraw my consent at any time.

Our services are on a pay what you can fee scale- please select what you are able to pay today.

Sick note

If you are requesting over 3 days PLEASE NOTE: Some employers will require FMLA paperwork for absences longer than a few days. Check your job's cutoff with HR or your employee handbook. We do not complete FMLA at this time.

$30.00 Quantity

Sick note

If you are requesting over 3 days PLEASE NOTE: Some employers will require FMLA paperwork for absences longer than a few days. Check your job's cutoff with HR or your employee handbook. We do not complete FMLA at this time.

$25.00 Quantity

Sick note

If you are requesting over 3 days PLEASE NOTE: Some employers will require FMLA paperwork for absences longer than a few days. Check your job's cutoff with HR or your employee handbook. We do not complete FMLA at this time.

$20.00 Quantity

Annual Membership

up to 6

$100.00 Quantity

Total

Payment Methods

Fastlane Checkout

Choose from one of the PayPal options to make your payment.

Contact Info

Payment Info

Request a Work Excuse Note (Telemedicine)

Patient Information

Work Note Request Details

Our services are on a pay what you can fee scale- please select what you are able to pay today.

Payment Methods