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Dental Excuse Form Template

Easily Manage Dental Absences with This Template

Missing a dental appointment can leave you with logistical headaches, especially when notifying schools or employers. This dental excuse form template helps students and employees communicate their absences effectively. With this customizable template, you can streamline the process of providing necessary documentation, ensure professional communication with schools or offices, maintain accurate records, and support patient care with ease. Experience the convenience of using a ready-to-go form that meets WCAG standards for accessibility.

Patient full name
Date of birth
Patient phone number
School or employer name
This excuse is for
School
Work
Both
Other
Please Specify:
Appointment date
Appointment time
Type of visit or procedure
Exam/cleaning
Consultation
Filling
Extraction
Root canal
Orthodontic visit
Periodontal treatment
Other/unspecified
Patient attended the appointment
Yes
No
Medication provided today may impair activity
Yes
No
Excuse applies on
Excuse duration
Appointment time only
Remainder of the day
Full day
Two days
Other/see notes
Return to normal activities on
Additional notes or instructions
Activity restrictions (select all that apply)
No restrictions
No physical education or sports
No strenuous activity
No heavy lifting
No operating machinery
No driving while on medication
Soft diet only
Other/see notes
Practice or clinic name
Provider full name
Provider phone number
Provider email address
Authorized provider signature (type full legal name)
Date signed
I certify the information above is accurate and this excuse is issued by this practice
Strongly disagree
Disagree
Neither
Agree
Strongly agree
{"name":"Patient full name", "url":"https://www.quiz-maker.com/QPREVIEW","txt":"Patient full name, Date of birth, Patient phone number","img":"https://www.quiz-maker.com/3012/images/ogquiz.png"}
Paper art illustration depicting a dental excuse form for an article on FormCreatorAI.

When to use this form

Use this template when you need documented proof of a dental visit for work, school, or a caregiver. It is helpful after cleanings, exams, or procedures like fillings, extractions, or emergency treatment. You can generate a note that confirms attendance, recommended rest, and a return date, signed by the provider. HR teams and school administrators get clear details to excuse an absence and set modified duties if needed. If an employer requests validation, include details from a Dental exam form. When sharing information with a third party, pair the note with an Authorization to release dental information form to stay compliant.

Must Ask Dental Excuse Questions

  1. What was the appointment date and time?

    Capturing the exact window away lets employers or schools verify attendance and approve leave. It also supports any travel or recovery time your policy permits.

  2. What was the visit type or procedure performed?

    Stating a general visit type (exam, cleaning, filling, extraction, emergency) guides recovery expectations without revealing diagnosis details. This helps supervisors set appropriate duties and prevents overexertion.

  3. What activity or duty restrictions apply, and for how long?

    Listing limits such as no lifting, soft diet, or limited speaking, plus an end date, prevents misunderstandings. For cases needing clearance to resume sports or strenuous work, reference your Dental clearance form.

  4. What is the recommended return date and any follow-up visit?

    A clear return date and any required follow-up set expectations for scheduling and attendance systems. It reduces back-and-forth and helps managers plan coverage.

  5. Who is the treating provider, and what is the clinic contact information?

    Including the dentist's name, license number, signature, and phone/email builds trust and speeds verification. It gives HR or registrars a single contact if questions arise.

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