We need the name of the parent/guardian authorized to request the note on behalf of the patient in order to approve requests on behalf of someone else.
Please provide the name of the person you are requesting the note on behalf of.
The legal parent or guardian of the patient (if the patient is a minor), OR
The legally authorized representative (such as someone with power of attorney or other legal authority) for the patient (if the patient is an adult)
and have the authority to make this request.
I agree
I understand
Note: Patient's under the age of 18 will need a guardian to be the point of contact for our doctors.
Please have your parent or legal guardian complete this request form.
We won’t disclose any personal details on your doctors note per HIPAA regulations.
This form is NOT a diagnosis or medical advice. It is only meant to help document your absence from work,school, or similar. DO NOT continue if you have any of the following symptoms.
Fever over 103°F
Difficulty breathing
Chest pain
Confusion or disorientation
Symptoms lasting over 10 days
Severe abdominal pain
Sudden dizziness
Uncontrolled bleeding
Severe allergic reaction
Thoughts of harming self or others
I confirm that I DO NOT have any of the above symptoms, I have read and understand the medical safety notice above, and I understand when to seek emergency care instead of telehealth.
This form is NOT a diagnosis or medical advice. It is only meant to help document your absence from work/school. DO NOT continue if you have any of the following symptoms.
I confirm that DO NOT have any of the above symptoms.
Your doctor's note WILL NOT include information about your illness or symptoms.
Your doctor's will use this information to review your doctors note request.
If yes, please contact emergency services or go to your nearest emergency room immediately. Trust Medical cannot provide the urgent care you need right now.
Call 911 immediately if you or someone else is in immediate danger or has attempted suicide
Go to your nearest emergency room
Stay with someone you trust until you can get help
Please review our mental health resources linked here and we encourage you to seek the appropriate help for your needs.
Doctors notes include: the doctor's full name, credentials, contact information, and letterhead.
We protect your privacy: When you need time away from work or school, we handle your information with care. We verify your absence while keeping your health information confidential. As required by HIPAA privacy laws, we only confirm attendance dates – never your medical details or diagnosis.
Our customers have rated us 4.9 out of 5 stars for our 100% issue resolution rate and 99% doctor's note acceptance rate.
I have read and agree to Trust Medical's request limit policy.
For compliance, excusal requests are limited to a maximum of 5 days within a 30-day period.
We need the exact date(s) you will be absent to include in your doctor's note.
We need to include your return date in your doctor's note.
We need the exact dates you will be absent to include in your doctor's note.
We need the exact date(s) you will be absent to include in your doctor's note
We need to include your return date in your doctor's note,
We'll match you to a doctor with the right availability that meets your timeline.
We'll match you to a doctor licensed in your state.
TrustMedical is the only doctors note service that offers a 100% money back guarantee if you run into issues with your note for any reason.
Did you know less than 1% of notes written by our medical team are rejected by work or schools?
Our customers rate us 4.9 out of 5 stars for our 100% issue resolution rate.
This email is where we'll send your approved doctors note.
We need this information to include in your letter.
Before you continue, please make sure your information is correct.
Full Name: @firstname @lastname
Date of Birth: @DOB
State: @state
Email: @email
IMPORTANT: We use this information for your doctor's note.
You'll get your doctors note first and a provider will follow up to discuss your options with anything else you select.
Your provider will get you a doctor's note first, and then reach out to talk through what treatment or medication might work for you.
PROGRAMS YOU MAY QUALIFY FOR:
FMLA: Job protected leave for up to 12 weeks. You maintain your position and benefits.
Paid Leave: Programs offer up to 90% of your wages covered while on leave. Most employees are covered through state programs or their employer.
You'll get your doctors note first and a provider will follow up to discuss your options for treatment. You can always change your mind later or request a refund on treatment.
This means your job is protected by federal law AND you can get paid while you're out. We provide and handle all the paperwork so you can focus on your health.
We will only reach out if we have questions about your case.
I agree to receive sms from Trustmedical.
Secure your spot with one of our doctors by checking out on the next page.
We'll match you to a licensed doctor in your state.
Receive a confirmation via email that your doctor is reviewing your intake form.
Receive your doctor's note within the hour.
Receive your doctor's note and treatment plan within the hour.
Receive your doctor's note and forms within the hour.
