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The following form may request personally identifiable or protected health information. Please see our Privacy Policy for details. This form is encrypted. SSL is on to ensure a higher level of security. A recaptcha must be completed before submission, you cannot save progress, and you cannot receive an email copy of the form.

Intake Form

  1. Family Child Health Referral Form

    Please complete the following information to refer yourself or someone else for Family Child Health Services.

    Rice County Public Health Nurses are available to answer your questions about pregnancy, a new baby, breastfeeding, parenting, immunizations, car seats, healthy homes, community resources, and more.

    If you have any questions or need assistance contact [email protected] or call 507-332-6111 and ask to speak to a Family Child health Nurse. 

    Discharge summaries or additional information can be faxed to 507-332-5932 or emailed to [email protected]

    For best results, use Internet Explorer to fill out this form.


  2. Who is completing this form?*
  3. Interpreter Needed*
  4. Family Status
  5. First-time parent ?
  6. Such as new mom/baby visit, prematurity, low birth weight, developmental concerns, prenatal visit, parenting support, etc.

  7. Please let us know of any additional information, comments, or medical considerations.

  8. Leave This Blank: