Non-Patient Medical Excuse Form
Request a general medical excuse without submitting sensitive health information. Please complete the required details below.
Full Name
*
First Name
Last Name
Your Relationship to the Individual (if applicable)
Email Address
*
example@example.com
Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Organization, Employer, or School Name
*
Recipient Contact (Name or Department)
*
Recipient Email Address
example@example.com
Date(s) of Requested Excuse
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Reason for Medical Excuse (do not include sensitive details)
*
Additional Comments (optional)
Submit Medical Excuse Request
Should be Empty: