Please use this form to send a request for an appointment for a school physical to the Dearborn Health Department. Parent or Guardian First Name: Parent or Guardian Last Name: Child's First Name: Child's Last Name: Street Address: City: St / Zip: Email: Telephone: Comments or Concerns:
Parent or Guardian First Name: Parent or Guardian Last Name: Child's First Name: Child's Last Name: Street Address: City: St / Zip: Email: Telephone:
Comments or Concerns: