Student Doctor’s Note

To Whom It May Concern,

This is to confirm that                                                           (Student Name) was evaluated by me on             /             /             and, due to medical reasons, is advised to refrain from school attendance from             /             /             to             /             /            . The student may resume academic activities on             /             /            , with or without restrictions as necessary.

If additional verification is needed, please contact my office.

Sincerely,

Physician's Name:                                                          
Medical Facility:                                                               

Contact Information:                                                        

Date:             /             /