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Doctor Note Template

[Doctor’s Name]

[Address]

[City, State Zip Code]

[Phone Number]

Date: ____/____/______

Please Excuse: ______________________________________________

From:

[__] Work

[__] Other__________________________________________________

Due To:

[__] Injury

[__] Illness

[__] Other__________________________________________________

For the following dates:

____/____/______ - ____/____/______

Thank You,

__________________________

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