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EDHS Referral to District Nurse
Online referrals are submitted electronically to the District School Nurse. Please fill out the form completely and hit the SUBMIT button at the bottom when completed.
* Indicates required question
Email
*
Record my email address with my response
Student Name
*
Your answer
Grade
*
9
10
11
12
Type of Referral- check all that apply
*
Vision
Hearing
Dental
Confidential Services
General Health Concern
Other
Required
Please provide a short description, if applicable, for the reason of the referral.
Your answer
Have you discussed this concern with the student?
*
Yes
No
Type of parent contact- check all that apply
*
None
Phone call home- spoke with Parent/Guardian
Left a voicemail with Parent/Guardian
Required
Is there any other information you would like to share regarding the referral?
Your answer
Your name and best method of contact
*
Your answer
Send me a copy of my responses.
Submit
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