Doctors Note Template 3
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Examples of a Doctors Note
Dr. Summit Falcon
1780 Hawkins Rd.
Fenton, MO 63026
Phone: 555-555-5555
Date: _________
Patient Name: Jane Doe
Diagnosis: Concussion
Restricitions/Clearance:
Jane is out of sports until further notice.
Dr. Signature

Dr. Summit Falcon
1780 Hawkins Rd.
Fenton, MO 63026
Phone: 555-555-5555
Date: _________
Patient Name: John Doe
Diagnosis: Left ankle sprain
Restricitions/Clearance:
John is able to return to sports but must wear an
ankle brace or get taped for practices and games.
Dr. Signature

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