Medical Absence Note

1
Enter Single Use Code* This field is required.(see back of the business card your doctor provided you)
See validation card
2
Please go back and recheck that you have correctly entered the validation code.
3
Patient Name* This field is required.
First Name
Last Name
4
Patient Email* This field is required.
Note will be sent to patient email
Confirm Email
5
Patient Phone Number* This field is required.
Area Code
Phone Number
6
Location of Treatment* This field is required.
Grande Prairie, AB
Lloydminster, AB/SK
Edmonton, AB
Select the city from list
7
Treating Physician - Grande Prairie, AB* This field is required.
Dr Thomas Peebles MD, Emergency Medicine, Grande Prairie, AB
Dr Colin Oberg MD, Emergency Medicine, Grande Prairie, AB
Select physician from list
8
Treating Physician - Lloydminster, AB/SK* This field is required.
Dr Colin Oberg MD, Emergency Medicine, Lloydminster, AB/SK
Select from list
9
Treating Physician - Edmonton, AB* This field is required.
Dr Felix Soibelman, MD, Emergency Medicine
Select from list
10
Dr Thomas Peebles Email
example@example.com
11
The validation code used does not match this physician. Please ensure you have selected the correct physician from the list.
12
Dr Colin Oberg Email
example@example.com
13
Dr Felix Soibelman Email
example@example.com
14
Note* This field is required.Type of Absence
Missed work due to medical reasons.
Missed school due to medical reasons.
Missed sport due to medical reasons.
Select from list
15
Number Days Absent* This field is required.
As approved by your physician
16
Number Weeks Absent* This field is required.From Sport Activity
1 weeks
2 weeks
3 weeks
4 weeks
5 weeks
6 weeks
7 weeks
8 weeks
Indefinitely / Remainder of Season
17
Validation CardOptional
Drag and drop files here
Select files to upload
Max. file size: 10.6MB
Browse Files
Attach picture of physician validation card
Cancelof
18
1st Day Absent* This field is required.
Date
Month
Day
Year
19
2nd Day Absent* This field is required.
Date
Month
Day
Year
20
3rd Day Absent* This field is required.
Date
Month
Day
Year
21
4rth Day Absent* This field is required.
Date
Month
Day
Year
22
5th Day Absent* This field is required.
Date
Month
Day
Year
23
6th Day Absent* This field is required.
Date
Month
Day
Year
24
7th Day Absent* This field is required.
Date
Month
Day
Year
25
7 days maximum.
26
Terms of Use* This field is required.You must agree to all terms for completion
I have completed this form accurately and truthfully
I agree to accept my medical absence note by email
I agree that my treating physician will receive a copy of this form submission by email
I agree to all terms selected
27
Form Payment* This field is required.Enter payment details and select next below
prevnext( X )
My Bag
1
My Bag
Great Product Name
$20
Quantity:1
Size:Small
RemoveEdit
Great Product Name
$20
Quantity:1
Size:Small
RemoveEdit
Great Product Name
$20
Quantity:1
Size:Small
RemoveEdit
Great Product Name
$20
Quantity:1
Size:Small
RemoveEdit
ORDER SUMMARY
GST + Transaction FeeCAD
SubtotalCAD
Total costCAD
Medical Absence Note
$50.00CADEdit
Back
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First Name
Last Name
28

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