Student Referral Form Student’s Name ______________________________________________ Grade _______________ Teacher _____________________________ Date____________ DOB_______________________ While observing the health of your child, the teacher and/or nurse have noted the following symptoms/signs which we feel should be brought to your attention: (Al observar la salud de su hijo(a), el maestro(a) y la enfermera, notamos los siguientes síntomas/señales que pensamos se debe traer a su atención.) VISION - AUDITORY - DENTAL - CARDIAC - OBESITY - ACANTHOSIS NIGRICANS – SCOLIOSOS - OTHER

Our observations are as follows: _______________________________________________________________________________________ Please take this form with you when you take your child to your: EYE DOCTOR - FAMILY DOCTOR - DENTIST - HEALTH CLINIC The school would appreciate comments from you or your doctor regarding this matter. The information you provide will be helpful for the nurse and the teacher to better serve your child. (La escuela apreciaría sus comentarios o de su médico tocante la salud de su hijo(a). La información que usted nos proporcione será útil para la enfermera y el maestro(a) para mejor cuidar a su hijo(a).) _______________________________ School Nurse/ Enfermera de Escuela

-------------------------------------------------------------------------------------------------------------------------INFORMATION FROM PHYSICIAN Diagnosis: __________________________________________ Treatment: ____________________ Medication: _______________________________ ____________ ________________ Medication/ Dosage prescribed At home: _______________

Frequency

Duration (number of days)

At School: _____________

Special Instructions: _______________________________________________________________ ______________________________ ________________________ __________________________ Physician Signature

Date

Telephone Number

I authorize LJISD School Nurse, or other designated school personnel, to give medication(s) as above. I authorize the medical provider to release health information to La Joya I.S.D _______________________________________________________ Signature of Parent Date

Phone Number (s) _______________________

RETURN TO SCHOOL NURSE WHEN COMPLETED. THIS IS NOT AN AUTHORIZATION FOR PAYMENT.