Nurse request form

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Nurse request form

Fill this out if you do not have an emergency and need to see the nurse. The nurse will come to the classroom or call you down by intercom.

电子邮件 *

在我的回复中记录我的电子邮件地址

What is your first and last name? *

What grade are you in? *

Who is your homeroom teacher? *

Which teacher gave you permission to request the nurse? *

Why do you need to see the nurse? Please try going to the bathroom, eating a snack, and drinking water for headaches and stomachaches. Try a cool paper towel for bumps and injuries that aren't hurting too bad. Your teacher has band aids for small scratches in the class. If those things do not help, you may fill out a form. *

I have a headache or stomachache. I tried water, snack, and going to the bathroom.

I have a bump, bruise, or injury that needs checked out.

I don't feel good and need my temperature checked.

I have a skin rash that the nurse needs to check out.

其他:

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