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Barnhart, MO
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Infants
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About Us
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Child Medical Exam
IDENTIFYING INFORMATION
CHILD'S NAME
(Required)
First
Last
BIRTHDATE
(Required)
MM slash DD slash YYYY
PARENT/GUARDIAN'S EMAIL ADDRESS
CURRENT STATE OF HEALTH
Based on my assessment of this child's medical history, ourrent state of health and my physical examination of the child on
(Required)
MM slash DD slash YYYY
this child can participate in a child care program. This child has no special care needs unless specified below.
(Date of medical examination must be within the last 12 month.)
PRYSICIAN'S INSTRUCTIONS FOR SPECIALIZED CARE
Complete this section only if child requires special care at a child care facility, e.g. special diets, allergies, ear infections, convulsions, diabetes, asthma, behavior problems, hearing or visual impairment, etc. (Attach additional pages as needed.)
Attach additional pages as needed
Max. file size: 300 MB.
SIGNATURE OF PHYSICIAN OR REGISTERED NURSE UNDER THE SUPERVISION OF A PHYSICIAN
(Required)
Date
(Required)
MM slash DD slash YYYY
PHYSICIAN'S OR NURSE'S NAME (PLEASE PRINT)
NAME AND ADDRESS OF CLINIC, GROUP, PRACTICE OR OTHER (MAY USE STAMP)
IF NURSE IS SUPERVISED BY A PHYSICIAN, INDICATE PHYSICIAN'S NAME (PLEASE PRINT)
TELEPHONE NUMBER
TO BE FILED IN CHILD'S RECORD AT CHILD CARE FACILITY
Home
Programs
Infants
Toddlers
Twos
Preschool
Pre-K
About Us
About Us
Careers
Why Choose Us
Parent Reviews
Location
Parent Corner
Contact Us
We're Hiring!
Inquire Now
Call
Email
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