243 Crescent Street, Brockton, MA  02302
508-588-2700

 DATE _____________________
 

TIME _____________________
 

PHYSICIAN’S FORM
 THE PHYSICIAN MUST FILL OUT THIS FORM BEFORE THE CHILD MAY RETURN TO CHILD CARE.
Child’s Name: ____________________________________________________________
Date of Birth: ____________________________________________________________
Classroom #: ____________________________________________________________
Teacher’s Name: ____________________________________________________________
Reason for concern: ____________________________________________________________
Was child sent home: ___ Yes          ___ No

Supervisor's signature:

 ____________________________________________________________

TO BE FILLED OUT BY PHYSICIAN:

Was seen in our office on:  ____________________________________________________________
Is being treated for __________________________ which requires he/she take the following medication:
Name of medication: ____________________________________________________________
Dosage: ____________________________________________________________
Duration: ____________________________________________________________
Time to be given: ____________________________________________________________

Contagious to others?

___ Yes          ___ No

Date child can return to school:

 _______________________________________________
Comments: ____________________________________________________________
Physician's Name: ____________________________________________________________
Address: ____________________________________________________________
Phone: ___________________ Fax: __________________