Mercer County Intermediate School Health Clinic Referral Form

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Mercer County Intermediate School Health Clinic Referral Form

CARE CLINICS ARE OPEN EVERY DAY THAT SCHOOL IS IN SESSION. (Referral accepted 7:45 AM to 2:45 PM)

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* Indicates required question

Who is referring the student? *

Your answer

Tell us about this referral *

I am a staff member, referring a student

I am a parent

Cell Phone (text or call) or Extension of Person Submitting Referral

Your answer

Name of individual being referred? *

Your answer

Briefly describe the reason for referral? *

Your answer

Please describe any measures taken prior to sending student to the nurse?

Your answer

Submit

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