DOCTOR’S NOTE TO SCHOOL
Note: All items must be filled out completely by the Doctor/Nurse.
TYPE OF VISIT: ꭐ IN OFFICE ꭐ TELEPHONIC
DATE: ___________________________________________
NAME OF STUDENT: ___________________________________________
LOCATION OF VISIT: ___________________________________________
PARENT/GUARDIAN: ___________________________________________
DR. SEEN: ___________________________________________
TIME IN/OUT: ___________________________________________
MAY RETURN TO SCHOOL: ꭐ IMMEDIATELY ꭐ__________________________ (Specify date for return)
WITH THE FOLLOWING RESTRICTIONS (if any)
_________________________________________________________________
_________________________________________________________________
DOCTOR’S SIGNATURE: ____________________________________________
Note to Parents: The school may verify this note with the doctor’s office to ensure accuracy.
*Adopted: 11/14/16
*Revised: 11/11/19
