Boyertown Area High School – School Physical Exam Health Room Phone 610.473.3670 Fax 610.369.7350

To the parent/guardian of ____________________________________ Grade/HR: __________ The PA school health code requires a physical exam or well-check for students in 11th Grade and for any student with incomplete health records. To meet this requirement, your child may have a physical done at school by the BASD healthcare provider. The date and time for the exams will be determined based on the number of requests for school exams; the school nurse will notify you of the date and time once the school exam are scheduled with the BASD healthcare provider. Please indicate below which option you will be using to meet this state requirement, sign and return this form tomorrow: _____ I would like my child to have a School Physical Exam*. (A school physical meets the state requirement but should not take the place of your child's regular physical with their primary care provider.) _____* I (parent/guardian) would like to be present during this physical exam. I understand the school RN will notify me of the scheduled time and that the physical will begin promptly at that scheduled time. If I am late for any reason, I understand the physical will be done as requested. List any special concerns you would like the medical provider to know: ______________ ___________________________________________________________________________ _____ My child will have a Private Physical Exam on ____________ (must provide date) with _________________(must provide name of MD or practice) and I will have the attached physical form completed and returned to the health room/school RN.

_____ My child had a Private Physical Exam on ____________________ (must provide date) and is on file at office of _________________________________ (must provide name of MD or practice).

__________________________________________________________________________________ Parent / Guardian Signature Date

DPS – Revised 06/12/14