Non-Urgent Health Office Request (Capital HS)   READ before completing the form
DO NOT EXPECT AN IMMEDIATE RESPONSE.

YOU ARE ALSO WELCOME TO STOP BY AT PASSING, BREAK OR LUNCH without a request.

No visits (unless urgent) after Lunch (5th period)

ITEMS not available:
- allergy medication
- cough drops
- cold/cough medication
- food
- water or cups

Please complete this request form.  I will send a call slip to you when there is availability in the health office. If you are feeling sick, have been injured, or have an immediate medical concern (for example - bloody nose, brain break, diabetes concern, etc.) please ask your teacher to call the nurse's office for more immediate assistance.

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Email *
First Name *
Student Last Name *
Visit request reason, check all that apply *
Required
Please give a brief description of your concerns or need to see the school nurse. *
Visit Goal *
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? *
Submit
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