School Absence Form printable pdf download

School Absence Form

School Absence Form: Medical Note

Atlanta Classical Academy

Student Name: __________________________________________________________

Grade: ________

To be filled out by healthcare provider:

Appointment Information

Date:_______________________

Time:____________________

The above named student/patient was seen in this office by the:

o Physician

o Nurse

o Nurse Practitioner

o Office Staff

o Physician Assistant

o Other _____________________

Diagnosis: ____________________________________________________________________

______________________________________________________________________________

Restrictions/Clearance:___________________________________________________________

______________________________________________________________________________

Patient May Return to School On:__________________________________________________

Day

Date

□

I have included more information on the back of this sheet.

□

I have included more information as a separate document.

Healthcare Provider Name: _______________________________________________________

Address: ______________________________________________________________________

______________________________________________________________________________

Telephone: _______________________

Fax: ___________________________

Healthcare Provider’s Signature: ___________________________________________________

Parents/Guardians:

Please remember to talk to the school nurse to review your child’s medical forms if your child:

o will need any special accommodations

o if any changes are being made to your child’s medications, health management plan,

allergy list, or prescribed diet

o if you have any questions or concerns

School Absence Form