Request a note for school or work from a doctor

1
Full Name* This field is required.
First Name
Last Name
2
Date of Birth* This field is required.
Date
Month
Day
Year
3
Email* This field is required.
example@example.com
4
Phone Number* This field is required.
Please enter a valid phone number.
5
State of Residence* This field is required.
Please Select
Please Select
Alabama
Arizona
California
Colorado
Connecticut
Delaware
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
North Carolina
North Dakota
Ohio
Oklahoma
Pennsylvania
South Carolina
South Dakota
Tennessee
Texas
Utah
Washington
West Virginia
Wisconsin
Wyoming
We currently provide telehealth services in these states only.
6
What state are you physically located in RIGHT NOW?* This field is required.Telehealth services are provided based on your current physical location, which may differ from your home state.
Please Select
Please Select
Alabama
Arizona
California
Colorado
Connecticut
Delaware
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
North Carolina
North Dakota
Ohio
Oklahoma
Pennsylvania
South Carolina
South Dakota
Tennessee
Texas
Utah
Washington
West Virginia
Wisconsin
Wyoming
7
Important: Georgia requires a live video evaluation for new patients. Asynchronous (form-based) visits are not available for patients currently in Georgia. Please book a video visit instead at teledirectmd.com. If you have been seen by TeleDirectMD before, you may continue.
8
Upload a photo of your government-issued ID (front)* This field is required.Driver's license, state ID, or passport. Stored securely per HIPAA.
Drag and drop files here
Select files to upload
Max. file size: 10.6MB
Cancelof
9
What type of note do you need?* This field is required.
Work excuse note
School excuse note
10
Select all symptoms you are currently experiencing:* This field is required.
Fever or chills
Cough or sore throat
Nasal congestion or runny nose
Body aches or fatigue
Headache or migraine
Nausea, vomiting, or diarrhea
Other (please describe below)
11
Please describe your symptoms* This field is required.
12
How long have you had these symptoms?* This field is required.
Less than 24 hours
1-3 days
4-5 days
More than 5 days
13
For symptoms lasting more than 5 days, we recommend a live video evaluation for your safety. Your $39 will be credited toward a $49 video visit (only $10 additional). Please book a video visit at teledirectmd.com or continue if you'd like a physician to review your async request.
14
Are your symptoms:* This field is required.
Getting better
About the same
Getting worse
15
Upload a photo of your Rash, wound (optional)
Drag and drop files here
Select files to upload
Max. file size: 10.0MB
Cancelof
16
Are you experiencing any of the following RIGHT NOW?* This field is required.
Chest pain, chest pressure, or chest tightness
Severe difficulty breathing or shortness of breath at rest
Sudden severe headache, confusion, slurred speech, or facial drooping
Sudden weakness or numbness on one side of the body
Loss of consciousness, fainting, or seizure
Uncontrolled or heavy bleeding
Severe allergic reaction (throat swelling, difficulty swallowing)
Severe abdominal pain
Vomiting blood or coughing up blood
Thoughts of harming yourself or others
None of the above — I am not experiencing any of the above symptoms
17
⚠️ STOP — Emergency Symptoms DetectedBased on your answers, your symptoms may require emergency medical attention. Please call 911 or go to your nearest emergency room immediately. This form cannot process your request. Do NOT wait for an online evaluation. If you believe you selected an option in error, please go back and correct your response. No payment has been charged.
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Large
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Ok
18
Please confirm ALL of the following:* This field is required.
This is NOT related to a workplace injury or workers' compensation claim
I am NOT requesting FMLA, disability, or extended leave documentation
I am 18 years of age or older
The information I have provided is truthful and accurate
19
First day of absence* This field is required.Must be within the last 3 days. We cannot provide documentation for absences that began more than 3 days ago.
Date
Month
Day
Year
20
Number of days to be excused* This field is required.
1 day
2 days
3 days
21
Expected return date* This field is required.
Date
Year
Month
Day
22
Who do you want the note to be addressed to* This field is required.
To whom it may concern
Specific person
23
Please specify the name* This field is required.
24
CONSENT FOR ASYNCHRONOUS TELEHEALTH SERVICES: By signing below, I consent to receive medical services from TeleDirectMD through asynchronous (non-real-time) telehealth. I understand that a licensed physician will review my submitted information without a live video or phone interaction. I understand this service is limited to work/school excuse documentation for short-term illness. If the physician determines that my request cannot be fulfilled, I will receive a full refund. I attest under penalty of perjury that all information provided in this form is truthful and accurate. This note is based solely on patient-reported symptoms and is not intended for use in workers' compensation claims, disability determinations, or legal proceedings. FREQUENCY POLICY: This service is intended for occasional use for acute illness. TeleDirectMD limits this service to a maximum of 2 requests per 30-day period and 4 requests per 6-month period. Patients exceeding these limits may be referred for comprehensive medical evaluation via a live video visit. TeleDirectMD reserves the right to decline requests that do not meet clinical criteria for asynchronous evaluation.
25
Patient Signature* This field is required.
26
Work/School Excuse Note - Physician Review* This field is required.
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ORDER SUMMARY
Total costUSD
Work/School Excuse Note - Physician Review
$39.00Edit
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Total cost $0.00
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