Medical Leave Note Request Form

Medical Leave Note Request Form

Provide the details needed for your leave note and the dates you need excused.
Attestation*

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.
Full Legal Name*

First NameLast Name
Date of Birth*

MonthDayYear
Date
Email Address*
example@example.com
Phone Number*
Please enter a valid phone number.Format: (000) 000-0000.
Note Type*

WorkSchoolOther
Reason for Leave*
Include prior diagnosis if this is a flare up, any at home testing and results and any other relevant details.
First Day to Excuse*

MonthDayYear
Date
Last Day to Excuse*

MonthDayYear
Date
Additional Comments (Optional)
Attestation*

The above information is accurate. This medical leave note does not replace proper medical care. If my symptoms continue or get worse, I will seek urgent medical attention.
Should be Empty: