Doctors Excuse Request Form
Please fill out all fields of the form. Once form is received I will send you an invoice to pay for the doctors note. Doctors notes are $35. Notes will not be created until payment is received.
Name
First Name
Last Name
Birthdate
-
Month
-
Day
Year
Date
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Visit Date
-
Month
-
Day
Year
Date
Return to School/Work Date
-
Month
-
Day
Year
Date
Turn Around Time is 24 Hours. There is a $10 Additional Fee For 2 Hour Turn Around. Would You Like 2 Hour Turn Around?
Yes
No
Email
example@example.com
TERMS & CONDITIONS
By signing I acknowledge that filling out this form does NOT guarantee my product will be delivered. Product will only be delivered after payment is rendered through impending invoice. Upon receipt of payment I will receive the product through email within 24 hours, unless additional fee has been paid for expedited delivery.
Signature
*
Submit
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