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Doctor’s Note for Work
[DOCTOR’S NAME]
[ADDRESS]
[CITY, STATE ZIP CODE]
DATE: ___/___/_____
PLEASE EXCUSE: _____________________________________________
FROM:
___ Work
___ OTHER: _______________________________________________
DUE TO:
___ INJURY
___ ILLNESS
___ OTHER: _______________________________________________
FOR THE FOLLOWING DATES:
___/___/_____ TO ___/___/_____
Thank you,
_________________________________________________________
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