Clinic Forms

Ensuring all students learn and grow is our collective responsibility.

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Clinic Forms

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School Nurse

Clinic Forms

Clinic Forms

School Clinic Forms

Diabetic Health/Care plan

physician and parent completed. Please send in medication and snacks for student and medication form.

Seizure Health/Care Plan

physician and parent completes and send to school with medication and medication order form.

Asthma Health/Care Plan

physician and parent complete and send to school with medication order and medication.

EpiPen Health/Care Plan

physician and parent completes and send to school with Epipen and medication order.

Peanut Free Lunch Table Permission Form

IF your child has an allergy and you want him to sit at a separate table to provide cross contact for peanut and nut allergies.

Emergency Medical Authorization

ODH Physical Examination

Ohio Department of Education School and Adolescent Health Physical Examination Form -- to be completed by your doctor

End of year medication form

To tell how how to send medication home at end of year.

ODH medication Form

Form has Epi-pens and inhaler boxes for physicians to complete.

Medication Request Form

Doctor completes medication portion and parent sign bottom portion.

Dental Sealants

PROTECT YOUR CHILD'S TEETH FROM DECAY

We partner with the Licking County Health Department to offer a dental sealant program for our 2nd graders. An information packet will be coming home in backpacks. Please review and return the form to school letting us know if you would like your student to participate.

LMH Dental program

Vision Screen physician Form

To be completed by physician if child has a referral to be evaluated due to not passing at school.

Hearing Screen Physician Form

To be completed by physician if child has a referral to be evaluated due to not passing at school.

Vision Screen Wavier

Complete if you do not want your child to have a vision test.

Hearing Screen waiver

please complete if you do not want your child to have a hearing screen done.

Heath City School District
107 Lancaster Drive, Heath, OH 43056
Phone: 740-238-7110 | Fax: 740-238-7053

Heath High School
300 Licking View Drive, Heath, OH 43056
Phone: 740-238-7150 | Fax: 740-238-7079

Heath Middle School
310 Licking View Dr, Heath, OH 43056
Phone: 740-238-7140 | Fax: 740-238-7072

District Nurse and Building Clinics
Phone: 740-238-7115 | Fax: 740-238-7116

Stevenson Elementary
152 Cynthia Street, Heath, OH 43056
Phone: 740-238-7130 | Fax: 740-238-7066

Garfield Elementary School
680 South 30th Street, Heath, OH 43056
Phone: 740-238-7120 | Fax: 740-238-7060

107 Lancaster Drive, Heath, OH 43056
P: 740-238-7110

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