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Doctor Excuse Form for School/Work

This document contains two doctor's excuse forms from The Children's Clinic at NAM in Houston, Texas. The first form is for Samuel A. Goodwin excusing him from school/work on January 30, 2007 and allowing him to return on January 31, 2007. The doctor's comments instruct Samuel to apply Nystatin cream and keep the areas clean to prevent spreading, with a follow up appointment on February 6, 2007. The second form is for Kristen Hutchison excusing her from work on January 30, 2007 due to illness of her child, allowing her to return to work on January 31, 2007.

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3K views2 pages

Doctor Excuse Form for School/Work

This document contains two doctor's excuse forms from The Children's Clinic at NAM in Houston, Texas. The first form is for Samuel A. Goodwin excusing him from school/work on January 30, 2007 and allowing him to return on January 31, 2007. The doctor's comments instruct Samuel to apply Nystatin cream and keep the areas clean to prevent spreading, with a follow up appointment on February 6, 2007. The second form is for Kristen Hutchison excusing her from work on January 30, 2007 due to illness of her child, allowing her to return to work on January 31, 2007.

Uploaded by

nipanipa
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as PDF, TXT or read online on Scribd
  • Doctor Excuse Form: A template for a doctor's note outlining the patient's treatment details and recommendations for school or work leave.

The Childrens Clinic at NAM

Drs. Heather Callaway, Sheela Lahoti & Kim Smith, Pedatrics


15555 Kuykendahl, 3rd Floor Houston, TX 77090
281-885-4630
After Hours & Weekends: 713-500-5808
Doctor Excuse Form

Certificate for school or work:


_Samuel A. Goodwin______________________ was under my care on
_January 30, 2007_____________ he/she will be able to return to
school/work on __January 31, 2007_________.
Doctors Comments: Apply Rx Nystatin Cream to lesions every 4 to 6 hours. Keep from
scratching or other irritations. Also, keep areas well cleaned to prevent from spreading. Will see
Samuel for follow-up appointment in one week on February 6, 2007 at 10:30 a.m. If any
questions or condition worsens contact doctor immediately._______
______________________________________________________________________________
______________________________________________________________________________
____________________________________________________________

Certificate for school or work:


_Kristen Hutchison ______________________ was under my care on _January
30, 2007_____________ he/she will be able to return to school/work
on January 31, 2007
___________.
Doctors Comments: Kristen was unable to attend work due to the illness of her child .
__________________________________________________________________
______________________________________________________________________________
__________________________________________________________________

1/30/2007

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Downloaded from [Link]

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