DOCTOR'S NOTE REQUEST AND SUBMISSION CHECKLIST
Preparation worksheet for a patient, parent or clinic team. The clinician issues the medical note.

REQUEST
Purpose: appointment attendance / absence / return with restrictions / accommodation / leave certification
Employer, school or other intended recipient:
Applicable workplace or school policy / form / jurisdiction:
Submission deadline and accepted delivery method:
Person or office that can clarify the requirements:

INFORMATION TO BRING TO THE CLINIC
Actual appointment date(s):
Dates missed or expected to be missed:
Which dates occurred before assessment, and the source of that history:
Relevant job duties or school activities:
Specific question the clinician is being asked to answer:
Requested review or return date (for clinician assessment):
Recipient's required identifiers; avoid unnecessary identifiers:
Information-sharing preferences / authorization to discuss with the clinic:

CHECK THE ISSUED NOTE
[ ] Correct person and intended purpose.
[ ] Actual issue date and assessment date are clear.
[ ] Any absence period is distinct from the appointment date.
[ ] Restrictions state the activity and duration or review date.
[ ] Expected return is distinguishable from confirmed fitness for a specific task.
[ ] Any earlier history is attributed accurately.
[ ] Information is limited to the request's purpose and authorized disclosure.
[ ] Issuing clinician's name, credentials, signature/authentication and practice contact are present.
[ ] Required leave or accommodation information is supplied through the appropriate process.

SEND AND FOLLOW UP
Final version / issue date:
Submitted to / route / date:
Receipt or acknowledgment:
Question or correction requested:
Clinic contact / owner / next checkpoint:
Replacement version issued by the clinician, if needed:
Employer or school decision / date / unresolved item:
Keep your copy; ask the issuing clinic to correct clinical statements or dates.