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Request to My Clinician for a Work or School Note
Get your Request to My Clinician for a Work or School Note in 3 easy steps
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01 Fill and edit template
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Who is this form for?
A patient, or a parent or guardian for a child, who asks their own clinician or practice for a note for work or school. The person asking completes and signs the request; the clinician decides whether to write a note and what it says.
What does it contain?
The practice or clinician it goes to; the names of the person asking and of the patient, and the relationship if the request is for a child; contact details; the date of the request and of the appointment or assessment, if known; the organization the note is for, any instructions or attachment from the employer or school, and the dates the note should cover; the type of note and the attendance confirmation or functional advice requested; the delivery preference; and the signature and date of the person asking. The form says: "The clinician decides whether and what to issue in a separate document."
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Fillable online Request to My Clinician for a Work or School Note