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Mercer County Senior High 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
Name of person submitting form
*
Your answer
Tell us about this referral
*
I am a staff member, referring a student
I am a parent/guardian, referring my child
I am a student
Cell Phone (text or call) or Extension of Person Submitting Referral
Your answer
Name of individual being referred
*
Your answer
Briefly describe reason for referral
*
Your answer
Please describe any measures taken prior to sending student to the nurse.
Your answer
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