Doctor Excuse Form printable pdf download

Doctor Excuse Form

The Children’s Clinic at NAM

Drs. Heather Callaway, Sheela Lahoti & Kim Smith, Pedatrics

15555 Kuykendahl, 3

Floor Houston, TX 77090

281-885-4630

After Hours & Weekends: 713-500-5808

Doctor Excuse Form

Certificate for school or work:

_Samuel A. Goodwin______________________ was under my care on

_January 30, 2007_____________ he/she will be able to return to

school/work on __January 31, 2007_________.

Doctor’s Comments: Apply Rx Nystatin Cream to lesions every 4 to 6 hours. Keep from

scratching or other irritations. Also, keep areas well cleaned to prevent from spreading. Will see

Samuel for follow-up appointment in one week on February 6, 2007 at 10:30 a.m. If any

questions or condition worsens contact doctor immediately._______

______________________________________________________________________________

____________________________________________________________

Certificate for school or work:

_Kristen Hutchison ______________________ was under my care on

_January 30, 2007_____________ he/she will be able to return to

January 31, 2007

___________.

school/work on

Doctor’s Comments: Kristen was unable to attend work due to the illness of her child .

__________________________________________________________________

______________________________________________________________________________

__________________________________________________________________

Doctor Excuse Form