H-601ASAN ANTONIOINDEPENDENTSCHOOL DISTRICT
STUDENT HEALTH SERVICES DEPARTMENT
MEDICAL SCREENING REFERRAL
To the Parent/Guardian of: Date of Birth: ID#:
The following condition(s) was/were found during a screening program or nursing assessmentconducted by Student Health Services staff.
______
Date
Date
The condition(s) listed above should be examined by your doctor as soon as possible
The condition(s) listed above is/are NOT serious and it is NOT necessary to see your doctor immediately.
At your next regular visit, ask about it. We suggest you have it checked no later than 3 6 9 months from now. (Circle One)
If you need more information or help in locating a doctor, please call your school nurse.
School Nurse School
DatePhone Number
Note to Parent: The District school nurses and nurse practitioners perform many nursing assessments. When medical treatment appears necessary, referral is made to a doctor or other health care provider. The nurse assessments are provided as a free service. Any charges by a doctor or other health care provider, or charges for medication, are the responsibility of the parent or legal guardian.DOCTOR'S REPORT TO SCHOOL NURSE
Findings and recommendations given to parents:
Are any modifications of the school program indicated? If so,what?
When may the student return to school? ______
Do you wish to see the child again? Yes No If so, when?
Physician's Printed Name Physician's Signature
Phone Number Date
PLEASE RETURN FORM TO SCHOOL NURSE AS SOON AS POSSIBLEReviewed 10/12
H-601B-SPDISTRITO ESCOLAR INDEPENDIENTE DE SAN ANTONIO
DEPARTAMENTO DE SERVICIOS DE SALUD ESTUDIANTIL
CONSULTA AL MÉDICO
Para los Padres/Tutores de: Fecha de nacimiento: ______ID#:______
Durante un programa de revisión o evaluación llevado a cabo por el equipo de los Servicios de Salud Estudiantil se descubrió la siguiente condición o condiciones.
Fecha
Fecha
Las condiciones mencionadas deben ser examinadas por su médico lo más pronto posible.
Las condiciones mencionadas no son serias y no es necesario consultar a su médico inmediatamente.
Consulte en la próxima consulta normal. Le sugerimos un examen a más tardar en meses de la fecha.
(3, 6, 9)
Si usted necesita más información o ayuda para localizar a un doctor, favor de llamar a la/elenfermera/o de la escuela.
Enfermera/o de la escuelaEscuela
FechaTeléfono
Nota para los padres: las/los enfermeras/los y las/los enfermeras/os de práctica avanzada del distrito escolar realizan muchas evaluaciones de enfermería. Cuando el tratamiento médico parezca necesario, se pide una consulta a un médico u otros proveedores de salud. Las evaluaciones de las/los enfermeras/osson gratis; cualquier cobropor un doctor u otro proveedor de salud o costos de medicamentos son la responsabilidad de los padres otutor legal.DOCTOR'S REPORT TO SCHOOL NURSE
Findings and recommendations given to parents:
Are any modifications of the school program indicated? If so, what?
When may the student return to school? ______
Do you wish to see the child again? Yes No If so, when? ______
Physician's Printed NamePhysician's Signature
Telephone NumberDate
PLEASE RETURN FORM TO SCHOOL NURSE AS SOON AS POSSIBLERev. 10/12