Pregnancy Verification Form printable pdf download

Pregnancy Verification Form

Pregnancy Related Services (PRS) Program

Pregnancy Verification Form

Date: ____________________

This is to certify that _______________________, __________________, was examined

Student’s Name

D.O.B.

in my office on ___________________________, and is ____________weeks pregnant

Date

and her expected date of delivery will be on ___________________________________.

Date

Other Recommendations:

________________________________________________________________________

__________________________

________________________

Physician Signature

Date:

_______________________________________

____________________________________

Address

Telephone

_______________________________________

____________________________________

City, State, Zip Code

Fax Number

****This form must be faxed back to the School Social Worker at (956)_________.

Mercedes ISD does not discriminate on the basis of race, religion, color, national origin, sex, age or disability in providing

education services, activities, and programs, including vocational programs, in accordance with the Title VI of the

Civil Rights Act of 1964, as amended; Title IX of the Educational Amendments of 1972; Section 504 of the Rehabilitation Act

of 1973, amended.

Pregnancy Verification Form