Mrs. Amanda Fischer RN,C BSN LSN

Ansonia Health Services

Mrs. Amanda Fischer RN,C BSN LSN

Parent;

Regarding your student______Grade______

This is a reminder that for the school year 2012-2013, I will need a Dr’s note regarding milk allergy/intolerance. We need your Dr. to sign this form so that juice may be substituted for milk for here at school.

If you could have your physician sign the specific area below and return to school.

Thank you for your help

Mrs. Amanda Fischer RN,C BSN LSN

Please send in by the first day of school

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Physician request for juice to be supplemented for milk product at school due to allergy or intolerance

Physician Signature Date:

This physician order will be in effect for 2012-2013 school year