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*

EmailTextPhone (only if necessary)

Date(s) to Be Excused From Work From*

Date

To

Date

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

$0.00

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