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Medical referral card

School _________________________________ Grade_______ Teacher ___________________________ Birthdate _______________ SS# ____________ LAS CRUCES PUBLIC SCHOOLS – MEDICAL REFERRAL CARD
__________________________________________________________________________________________________________________________________ Father’s Name __________________________________________________________________________________________________________________________________ Mother’s Name Please give the names of your family Health Care Provider and family dentist to be called in case your child becomes ill or has an accident at school and you cannot be reached. _______________________________________________ ___________________________ Hospital Preference □ Memorial Medical □ Mountain View Health Care Provider/Phone Insurance information: Please check all that apply: □ Health Insurance? Company _____________________ □ Medicaid/Salud? HMO ____________________ □ School Insurance □ No Insurance Please give the names of two relatives or friends who will assume responsibility for your child in case of illness or accident until you can be reached. Please notify these persons of these arrangements. In case of any changes in the names of these persons, please notify the school in writing. 1. _____________________________________________________________________________________________________________________ Name 2. _____________________________________________________________________________________________________________________ Name
Over-the-Counter Medication Consent
Occasionally, your child may unexpectedly need medication during a school day. For those occasions, we must have written parental permission.
The school nurse will assess your child and pertinent comfort measures will be tried first. Only the school nurse can administer the Over-the-Counter
Medication based on nursing judgment and as instructed on the medication label. Any student requiring such medication more than 3 times in one
month, or more than 3 days in a row will be referred for a medical evaluation. Elementary nurses will attempt in inform a parent before
administration.
The school nurse has my permission to administer the following nonprescription medication(s):
Tylenol (Acetaminophen) medication to reduce pain □ Yes □ No
Advil (Ibuprofen) medication to reduce pain □ Yes □ No Mylanta (Antacid) medication for upset stomach □ Yes □ No Throat spray/Cough drops for throat pain/mild coughing □ Yes □ No LAS CRUCES PUBLIC SCHOOLS – MEDICAL REFERRAL CARD
Please indicate if student has had or is currently under treatment for any of the following conditions: □ Asthma □ Tetanus Shot (Last Date ______________________) □ Other: _______________________________________________________________________________________________________________ ____________________________________________________________________________________________________________________ □ Allergies? ____________________________________ □ Long-term Medications: ___________________________________________ □ Use of Contact Lenses? □ Yes □ No □ Hospitalized for serious illness, surgery or accident? □ Have you ever been informed of the need to be on antibiotic therapy prior to dental treatment? □ Yes □ No □ If yes, identify required therapy: ________________________________________________________________________________________ □ Please add any problems not listed: ________________________________________________________________________________________ _____________________________________________________________________________________________________________________ _____________________________________________________________________________________________________________________ If, in the opinion of the principal/school nurse, service involving medical action or treatment is required and the parent cannot be contacted for consent, the parents hereby authorize school authorities to obtain medical service for or transport for medical service the above student. Nothing in this section shall be construed to impose liability on any school official or school employee who, in good faith, attempts to comply with this section. It is understood that I will be financially responsible for all emergency care. Signature of Parent/Guardian ________________________________________________________________ Date _________________________ Note: Parents are responsible for notifying the school about any change of information contained on this card. PLEASE RETURN IMMEDIATELY

Source: http://onate.lcps.k12.nm.us/Military%20Transition%20Pathway/School%20Forms/Medical%20Referral%20Card.pdf

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