Medical Leave Note Request Form

1
Basic Information
Full Name
Please enter your email
Please enter your phone
Date of Birth
2
Attestation* This field is required.
I am in Utah, this is not a live visit, my care is based on the questionnaire I submit, and I am not experiencing a medical emergency.
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Note Type* This field is required.
Work
School
Other
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Reason for Leave* This field is required.
Include prior diagnosis if this is a flare up, any at home testing and results and any other relevant details.
5
First Day to Excuse* This field is required.
Date
Month
Day
Year
6
Last Day to Excuse* This field is required.
Date
Month
Day
Year
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Additional Comments (Optional)
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Patient Attestation & AcknowledgementPatient Attestation and Acknowledgment: I certify that the information I have provided, including my symptoms, medical history, medications, allergies, and other requested information, is complete and accurate to the best of my knowledge. I confirm that I am physically located in the State of Utah at the time I submit this request for care.I understand that this is an asynchronous telehealth visit, meaning that I will not necessarily communicate with a healthcare provider in real time. A licensed healthcare provider will independently review the information I submit, along with any other available or requested clinical information, before making any diagnosis, treatment recommendation, or prescribing decision.I understand that the provider may request additional information, photographs, medical records, laboratory testing, a telephone or video visit, or an in-person evaluation if needed to safely evaluate or treat my condition. Submission of this questionnaire does not guarantee that treatment or a prescription will be provided.I understand that telehealth has limitations and that certain conditions cannot be safely diagnosed or treated through asynchronous care. If the provider determines that telehealth evaluation is not appropriate for my condition, I may be advised to seek in-person medical care.I certify that I am not currently experiencing a medical emergency. If I develop severe, rapidly worsening, or potentially life-threatening symptoms, I will not wait for a response through this service and will call 911 or seek care at the nearest emergency department.I understand that if my symptoms persist, worsen, change significantly, or do not improve as expected, I should seek additional medical evaluation as directed by my healthcare provider.
YESNO
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$20
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Headmeds Digit Consult
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Payment Methods
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