Non-Urgent Health Office Request READ before completing

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Non-Urgent Health Office Request READ before completing

DO NOT EXPECT AN IMMEDIATE RESPONSE.

DO NOT USE THIS OUTSIDE OF CLASS TIME. There is no way I can find you during non class times.

Do not use this for emergencies.

A call slip will be sent in the order in which requests were made.

YOU ARE WELCOME TO STOP BY BEFORE SCHOOL, PASSING, BREAK OR LUNCH without a request.

5th period: Only emergent medical needs will be addressed. Teacher will call office/main office for emergencies.

Acetaminophen (Tylenol) and ibuprofen (Advil/Motrin) only administered with a parent consent on file.

Items NOT available:
- allergy medication - super glue
- cough drops - extra clothing
- cold/cough medication - Midol, Aleve or Pepto
- food - Any type of diagnosis

A call slip will be sent for you when there is availability in the health office. If you have an immediate medical concern (for example - bloody nose, concussion, bone break, diabetes concern, passing out etc.) please ask your teacher to call the nurse's office for more immediate assistance.

Email *

First Name *

Student Last Name *

Visit request reason, check all that apply *

Heacache

Cramps

Tired

Emotional

Upset stomach

sore throat (please note below when it started and any other symptoms)

skin concerns (if you need a band-aid, check with your teacher)

sore body part (muscle soreness/injury) NO ACE bandages available

Eye/contact concern

Concussion/brain break

Seasonal Allergies (note, the nurse does not have allergy medication)

Other:

Required

Please give a brief description of your concerns or need to see the school nurse. *

Visit Goal *

to obtain tylenol, ibpuprofen or supplies

to rest

to talk

ice pack

other:

Any other information the nurse needs to know (ex: I hit my head over the weekend, sore from working out, I had a fever yesterday, etc) *

Have you already contacted your parent or guardian about this issue? *

Yes

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