Return To Work Letter

Email *

First Name *

Last Name *

Phone

Date of Birth *

Confirm Date of Birth *

Check to confirm date of birth

Gender *

Weight *

Height *

Race

Other Race *

Marital Status

Why are you consulting? *

Select Your Location *

Let's match you with an authorized medical professional in your state.

Consent to use information *

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Agreement for Online Consultation *

By signing this document, I certify that I am requesting a clearance letter for actual medical needs. I understand that getting a doctor's note by giving false or misleading information is against the law and could result in legal action.
I am aware that a clearance letter is not meant to be used as justification for skipping work or class. This letter certifies that you are well enough to resume your normal activities.

Are you prepared to pick up your regular activities—school, work, etc.? *

I am capable of carrying out my daily tasks since I am both physically and intellectually fit.
I am presently unable to resume my normal daily routines.

Stop! You must be physically and mentally fit and able to carry out normal activities in order to receive a medical clearance for employment or school.

Was your absence from work originally granted by a physician or other health care provider? *

Yes, I have a letter in writing apologizing for my absence.
A medical expert did NOT give me a pass.

The purpose of my visit *

Letter of medical clearance to return to work or school
Letter of apology to be sent no later than three days from today
Apology letter for days other than today

Organization asking for this letter

Employer
School
Government
Insurance
Other

List other organization *

How many days did you miss work or class? *

Less than one week
7 -14 days
Less than one month
1 to 3 months
Over 3 months
Non-applicable
Other

Please specify

What was the main cause of the absence?

Minor health issues unrelated to COVID
COVID-19 positive
COVID symptoms
Close interaction with a COVID-19 patient
Minor injury
I was employed by a hospital or nursing home.
Pregnancy
Recently taken a flight
Having a medical emergency or condition that is life threatening
Disability
Mental illness
Chronic conditions like diabetes and high blood pressure
Other

STOP! Unfortunately, given how serious your situation is, we are unable to assist you.

List other main causes *

Describe the medical justification for this letter in full. *

What is the status of your COVID-19? Choose the one that best fits you.

Tested negative for COVID-19
Close interaction with a COVID-19 patient
Positive test for COVID-19
In the previous 15 days, I haven't had a COVID-19 test.
I have no worries about COVID.

Do you suffer from any of these ailments?

Immunodeficiency caused by HIV or malignancy
Liver disease
Heart disease
Hypertension
Diabetes
None of these conditions

Which of these ailments are you presently dealing with?

Fever or chills
Flu-like symptoms
Infection or wound
Uncontrolled hypertension or diabetes
Psychiatric symptoms
Experiencing extraordinary weakness, exhaustion, or physical aches
Nausea, Diarrhea or Vomiting
Pain or injury
Experiencing a life threatening condition or medical emergency
Chest discomfort or breathing issues
COVID symptoms
I'm not currently suffering from any symptoms or illnesses.

Which of these COVID-19 safety measures do you follow?

Social distancing
Quarantined for at least 10-14 days
Frequent COVID-19 testing
Working remotely or online classes
Mask or facial shield
Avoid traveling and public places
I don't follow any of these COVID safety measures.

What additional steps will be done to resume work or school safely? *

What other noteworthy information or background do you have to support the time off? *

Which way would you want to receive the letter? *

Send a copy to my email
Send this request to my job, school, or other organization.

Refund policy *

I am aware that after the letter is delivered, the consultation fee is not refundable.

Upload your COVID-19 test results or any accompanying medical documentation, as appropriate, to speed up the procedure (optional).

File Upload

Click or drag files to this area to upload. You can upload up to 3 files.

Do you have any further details you would like to present to the doctor today? (Optional)

Pharmacy Name *

Pharmacy Address *

Pharmacy Phone *

Billing Address *

Address Line 1

Address Line 2

City

State

Zip Code

Prescription fee

Price: $54.99

Stripe Credit Card *