Doctor’s Note Request Intake Form — Dossier - Total Healthcare Clinic

Contact Information

First Name

Last Name

Date of Birth

Email

Phone/Mobile

Type of Request

Doctor’s Note

Documentation Needed

Work/school absence note (illness, unable to attend)

Disability paperwork (for a claim)

Workplace accommodations (remote work, modified hours, equipment)

Other specialized forms

Something else (with space to specify)

Specify

Are you currently experiencing urgent or life-threatening symptoms?

Yes – I may be experiencing a medical emergency

No – I’d like to proceed with this request

⚠️ You may need immediate medical attention. Please call emergency services or go to the nearest ER.

Confirm if experiencing any of the following (check all that apply).

Fever > 103°F (39.4°C)

Difficulty breathing / shortness of breath

Severe abdominal pain

Sudden dizziness, fainting, or loss of consciousness

Uncontrolled bleeding

Severe allergic reaction (face/throat swelling, trouble breathing)

Thoughts of harming yourself or others

Reason for Absence

Mild illness (cold, flu-like symptoms)

Gastrointestinal issue (stomach bug, food poisoning)

Mild injury (sprain, minor pain)

Mental health reason (anxiety, burnout)

Other condition (with description field)

Specify

Symptom Duration

Less than 24 hours

1–2 days

3–5 days

More than 5 days

Current Status

Improving or stable

Still feeling about the same

Slightly worse but manageable — I just need a sick note

Feeling very unwell — I’d like a provider assessment (additional cost)

Requested Coverage

How many consecutive days are you requesting?

1–2 days

3–5 days

6–7 days

Start date of absence

End date of absence

Expected return-to-work/school date

Addressee

To whom should the note be addressed?

“To whom it may concern”

Specific person/organization

Name of Person / Oraganization

Policy Acknowledgment

I understand that this service provides sick notes for up to 7 days within any 30-day period, and confirm my request is within this limit.

Additional Notes

Please include any additional details you’d like the provider to know.