School Note Request

This form is to be completed by a parent or guardian to receive a school note from Hales Pediatrics. This is not a way to communicate health information and questions with our doctors.

Name Email Retype Email Phone Number Patient's Full Name Patient's Date of Birth The school note must include

How should we handle the completed form -- Select One -- Email to you Keep at office for pickup

I hereby attest that the above information is correct and that I am the patient’s parent or legal guardian.

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