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Clinical Reference Systems: Pediatric Advisor 10.0
School Excuse
Child's name __________________________________________________
Diagnosis _____________________________________________________
This child was home for medical problems from _______________ to
_____________________.
This child is now able to return to school and is not contagious.
Physical education:
___ Full activity
___ Limited activity as follows:
_______________________________________________________________
_______________________________________________________________
_______________________________________________________________
No gym for _____ days
Physician's name ______________________________________________
Physician's signature ________________________ Date ___________
Physician's phone number _________________________
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