Employee Doctor's Note Request Form
Use this form to request a doctor’s note related to an absence or return-to-work situation.
Full Name
*
First Name
Last Name
Employee Email Address
*
example@example.com
Department
*
Please Select
Human Resources
Finance
Operations
IT
Sales
Marketing
Other
Request Type
*
Absence
Return to Work
Date(s) of Absence or Return
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Doctor’s Note Needed By (Date)
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Preferred Method to Receive Note
*
Email
Pick Up in Person
Phone Number (Optional)
Please enter a valid phone number.
Format: (000) 000-0000.
Additional Comments (Optional)
Submit Request
Should be Empty: