
1
DOCTOR’S EXCUSE NOTE
Institution: ____________________________________________
Dr. ___________________________________________________
Address: ______________________________________________
Phone: ________________________________________________
Email: ________________________________________________
Date of examination: _______________, 20_____
Return appointment: _______________, 20_____
That is to certify that patient __________________________________ was under my care at my
office on _______________, 20_____. Please excuse this absence.
Health issue description:
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
EXAMINATION RESULT
□ Full Duty: may return to work\school without any restrictions or limitations.
□ Light Duty: may return to work\school with restrictions and\or limitations (described
below). Restrictions duration: _____________; Limitations duration: _____________;
□ Off Work: patient cannot return to work\school and is not able to perform their duties
until _______________, 20_____ or until next evaluation.