STUDENT Health - REFERRAL
For Faculty, Coaches, Admin, General Staff -

If you have a student health concern, or have been given student health information that you feel needs attention... Please fill out and submit this form.  It goes to the EHS NURSE & HEALTH OFFICE.

For EMERGENCIES requiring immediate attention contact us directly at (714) 962-1356 (Nurse - ext. 55430; Health Clerk - ext. 55429).

***All correspondence is confidential***
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STAFF MEMBER submitting this form: *
Required
YOUR NAME and the best way to reach you (if more information is needed) *
STUDENT NAME and/or ID # *
LOCATION // SETTING *
Required
LAST DATE in CLASS (or) PRACTICE *
STUDENT CONCERN // REASON for REFERRAL *
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