Mobile Units Enrollment Form 2026

Mobile Health Medical & Dental Clinics

Registration, Consent for Services and Disclosure of Personal Health Information
Name:

First NameMiddle NameLast Name
Gender:
Date of Birth:

MonthDayYear
Patient Ethnicity:
Patient Race:
Address:

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number:
Format: (000) 000-0000.
E-mail
example@example.com
Parent/Guardian Name:

First NameLast Name
Parent/Guardian Date of Birth:
School/Site:
Grade:
INSURANCE INFORMATION:

Please include all insurances if you have multiple forms of coverage.
If "Other Insurance", name of Insurance:
ID #
Group Number:
Contract Number:
Name of Insurance Holder:
Employer:
HEALTH HISTORY:

Please check each condition applicable to the patient.
Type a question
CURRENT MEDICATIONS - List all:
ALLERGIES - List all:
SURGERIES - List all:
If consenting to medical care, FHC will verify if the patient is up to date on required and recommended vaccinations. Please confirm your vaccination approvals below. You will be notified if your youth is given immunizations.
I approve the following:
REQUIRED for school entry:
RECOMMENDED by the CDC and our FHC Providers:
Services Available on the Mobile Medical & Dental Units

Primary Care Services:
1. Well Child Care and Early and Periodic, Diagnostic and Treatment (EPSDT) Screening and Exam
2. Comprehensive Physical Exams and Sports Physicals
3. Vision Screening
4. Hearing Screening
5. Health Education and Risk Reduction Counseling
6. Sexually Transmitted Disease (STD) Testing
Illness/Injury Care:
1. Minor Injury assessment, treatment and follow- up
2. Acute illness assessment, treatment, follow-up and/or referral
Chronic Conditions Care:

May include asthma, high blood pressure, obesity, allergies, skin conditions, etc.
1. Exam, diagnosis and treatment of a new condition
2. Maintenance and follow-up of existing conditions
Immunizations:
1. Screening and assessment using Michigan Care Improvement Registry (MCIR)
2. Administration of immunizations (with parent/guardian approval as indicated)
Dental and Oral Health:
1. Cleaning: The benefits include healthy gum tissue, elimination of odors and stains. After cleaning teeth and gums may be sensitive.
2. Fluoride Treatment: Fluoride varnish is painted on teeth to prevent tooth decay, delivering a safe and effective dose of flouride.
3. Sealants: Sealants help prevent decay on the chewing surface of a tooth.
Consent for Services

By signing I confirm that I am the patient over 18 or the parent/legal guardian of the patient named above. I confirm that I have the legal authority to give consent for their medical and dental care. I know that I can ask any questions about treatments that the patient may receive. I give the family Health Center (FHC) permission to do the following:
- Perform procedures and treatments that are deemed appropriate and to seek further emergency assistance, if needed.
- Release information regarding these services for purposes of receiving insurance payment.
- I understand I am responsible for charges not paid by insurance or will be billed based on my ability to pay.
- Allow dental or medical students under direct supervision of a licensed dental/medical professional to provide servies.
- As parent/guardian I understand that treament may be obtained at the patient's dental home/medical home rather than at the school clinic/mobile dental facility and that obtaining duplicate services at the clinic/mobile dental facility may affect benefits that the patient received from the medical/dental insurance.
- In an emergency, it is okay (I authorize) for an adult to seek medial help for my youth. If I have a question about any emergency related to my youth's medical or dental services, I may call the Mobile Unit Manager (269) 349-2641, Ext. 690.
- I understand that the Family Health Center Notice of Privacy Practices is posted online at https://www.fhckzoo.com/privacy-notice/. A hard copy can be obtained by calling (269) 349-2641.
This authorization will be kept on file and remain in effect until September 30, 2028. You have the right to have a copy of this form once it is signed. You have the right to cancel this consent or authorization at any time, in writing. If you cancel, it only applies to uses and services after cancellation date. If you would like a copy of this consent for your records, please call us at (269) 349-2641.
Please indicate which services you consent to for the patient:
Signature (Patient or Parent/Guardian if a minor)
Printed Name:
Date:
Email
example@example.com
Relationship to Patient:
MDHHS-6310, Michigan Care Improvement Registry (MCIR)

immunization notice

Michigan Department of Health and Human Services (MDHHS)

Division of Immunization

(Revised 3-26)

The Michigan Care Improvement Registry (MCIR) provides a place for your immunization history to be stored confidentially. MCIR is used as a tool and can help providers accurately determine if a vaccine is needed based on the recorded immunization history. MCIR collects and combines immunization information for Michigan residents of all ages. Information in MCIR is confidential and all MCIR users are held to strict security and confidentiality requirements.

Having immunization data in MCIR can:

·         Prevent harmful delays in medical care.

·         Prevent over or under vaccination for a person (i.e. missing a vaccine or getting a repeated dose).

·         Reduce healthcare burden by providing an accurate immunization history for providers to base their recommendations.

You have the right to object to having your child’s immunization(s) reported to MCIR, which is otherwise required by MCL 333.9209. Remember, if immunization information is not stored in MCIR, your provider might not have access to a complete immunization history, and it will be essential for you to keep your child’s immunization record for future medical visits, schooling or possible employment opportunities.

An immunization history can be printed by a healthcare provider. For those 18 years or older, you can print your immunization record yourself from the secure MCIR Public Portal.

The Michigan Department of Health and Human Services (MDHHS) does not discriminate against any individual or group on the basis of race, national origin, color, sex, disability, religion, age, height, weight, familial status, partisan considerations, or genetic information. Sex-based discrimination includes, but is not limited to, discrimination based on sexual orientation, gender identity, gender expression, sex characteristics, and pregnancy.
End of form
Signature
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Mobile Health Medical & Dental Clinics

INSURANCE INFORMATION:

HEALTH HISTORY:

If consenting to medical care, FHC will verify if the patient is up to date on required and recommended vaccinations. Please confirm your vaccination approvals below. You will be notified if your youth is given immunizations.

Consent for Services