200 Hillvue Lane, Pittsburgh, PA 15237

PHONE: 412-366-2100


Health Services Forms
Listed below are the Health Services forms most commonly used. To print the form, click on the name below and print. You will need to use your back button to return to this page after printing. If you have any questions about completing the form, please do not hesitate to call your child's school nurse.
 
 
 
This form is sent home to each student every school year. It should be completed and returned ASAP. Information should be updated as often as needed to be certain the Health Services staff can reach you in case your child is ill or injured . 
Medication Permission Form
This link takes you to the permission forms that should be completed when requesting medication be dispensed to your child during the school day.
Allergy Emergency Form
This form should be completed by you and your child’s physician indicated the steps to be taken if your child has a life threatening allergy. It’s important to note that if Benadryl is a part of the plan, the physician should include the written prescription for that medication.
Physical Exam Forms

 
 
 
This form should be completed by your child's Primary Health Care Provider for the following school years:
  • entry (Kindergarten or 1st)
  • grade 6
  • grade 11

This form should be completed by your child's Dentist for the following school years
  • entry (Kindergarten or 1st)
  • grade 3
  • grade 7
Absence Notes
Print this form when sending in an excuse for your child's absence. A written excuse is required for each absence.
 
This form can be used for the Health Care provider to specifically list what can be done in PE if restrictions need to be in place.
CLOSE