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Mineral County Schools 36 Baker Place, Keyser, WV 26726            Phone: 304-788-4200            Fax: 304-788-4204

Physician Referral

Physician Referral
MINERAL COUNTY SCHOOLS HEALTH SERVICES
Nancy Starcher 788-4220

Vancancy 726-4339

Trina Melody 788-4213

Sharon Clark 788-4216

One Baker Place

Keyser, West Virginia 26726

304-788-4200
Michael C. Burke, Director Eleanor Grubbs-Paull, Assistant




Date__________________________________



TO THE PARENTS OF: ______________________________________





Your child was seen today by the school nurse and revealed that:



Please take your child to the doctor of your choice since this is an abnormal finding. Your child will not be allowed to return to school until they have been seen by a physician.



_______________________________________ School Nurse






DOCTOR’S FINDINGS AND RECOMMENDATIONS





I have examined ___________________________________ Date______________________



Pertinent information:____________________________________________________________



_______________________________________________________________________________



_______________________________________________________________________________



_______________________________________________________________________________





_______________________________________

Physician’s Signature



Address:_______________________________

________________________________


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MINERAL COUNTY SCHOOLS: 36 Baker Place, Keyser, WV. 26726      |      Phone: 304-788-4200      |      Fax: 304-788-4204
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