MISSED EXAM OR DEADLINE: MEDICAL NOTE

[Clinic name]
[Address]
[Phone and email]

Note written on: [Today's date]
For: [Instructor, faculty office, or registrar, or To whom it may concern]

Student: [Full name]
Date of birth: [Date]
Student number: [If the student gives it, or delete this line]

VISIT
Seen by me on: [Date and time of the visit]
How: [In person, by video, or by phone]
Known to me before this illness: [Yes, an existing patient, or No]

THE ACADEMIC WORK MISSED
[Exam, test, or assignment, with its date or due date]

DATES AFFECTED
[First date] to [last date, or expected last date]
Found at my visit: [What you observed, in terms of what the student could and couldn't do]
Reported by the student: [Days before the visit, and what the student says they couldn't do on them]

DEGREE OF IMPACT
Rating: [One rating, on the school's scale if it has one, e.g. mild, moderate, serious, or severe]
In practice: [What the student could not do, e.g. sit a 2-hour exam on that date]
Expected to resume academic work: [Date]

Diagnosis: [Not included, unless the student asks for it]

I can vouch for what I assessed on the visit date above. Any dates before it rest on the student's account.

[Your name, credentials]
[Licensing body and registration number]
[Signature]

Verification: [Clinic phone or email. I will confirm only that I wrote this note]