Non-Urgent Health Office Request (Capital HS) READ before completing the form

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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.

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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