BHS- Parent/Guardian Request for Telehealth Appointment Space 
Parents/Guardian:  Please complete this form to reserve space for your student's telehealth appointment.  All telehealth appointments will be in the Health Services Office.  The space is private, and includes a desk and a computer (if needed) for the appointment.  A student will check in at the Health Services Office, attend their appintment in the assigned space, and check out to return to class at the end of the appointment.  

Any questions should be directed to Justice Trout, BHS Nurse, at 218-454-6278.
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  Parent Name (First and Last)

Parent Phone Number
Parent Email
Contact Person Email/Phone Number (We must have a contact should there be a conflict in time and request needing to be DECLINED.) *
Student Name (First and Last)

 *
Student's Grade: *
Appointment Date
MM
/
DD
/
YYYY
Appointment Time
Time
:
Is this appointment reoccurring? Please state the reoccurrence schedule below.
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