Urgent Care Work Release Form
Please fill out the following information to request a work release from urgent care.
Full Name
First Name
Last Name
Date of Birth
-
Month
-
Day
Year
Date
Phone Number
Please enter a valid phone number.
Email Address
example@example.com
Date of Injury or Illness
-
Month
-
Day
Year
Date
Symptoms
Doctor's Name
First Name
Last Name
Doctor's Phone Number
Please enter a valid phone number.
Have you been seen by a healthcare professional for this injury or illness?
Yes
No
If yes, please provide details
Are you currently taking any medication?
Yes
No
If yes, please provide details
Have you been admitted to the hospital for this injury or illness?
Yes
No
If yes, please provide details
Do you have any allergies?
Yes
No
If yes, please provide details
Submit
Should be Empty: