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Medical Service Request Form
Medical Service Request rev20231206
Patient Name
(Required)
First
Last
Parent/Guardian Name (If patient is under 18 years old)
First
Last
Phone
(Required)
Email
What school does your child attend?
(Required)
Not Applicable
Catherine Kolnaski Magnet School
Ella T. Grasso Technical School
Gales Ferry School/Juliet W. Long School
Gallub Hill School
Groton Middle School
Fitch Senior High School
Ledyard Middle School
Ledyard High School
Mystic River Magnet School
Thames River Magnet School
Bennie Dover Jackson Middle School
Jennings Elementary School
Nathan Hale Elementary School
New London High School
Regional Multicultural Magnet School
Winthrop Elementary School
Stonington Middle School
The Friendship School
Harbor Elementary School
Barnum Elementary School
Northeast Academy Elementary School
Stonington High School
West Vine Street School
Other
Services requested
(check all applicable)
Physical
Flu vaccination
Other vaccination
Other service
Disclaimer:
We are currently receiving a high volume of requests for services. Please expect return contact for scheduling in
2-3 days
. For urgent or emergent requests please call 911, or go to the nearest emergency department for assistance.
