NoPo Blueberry Consent Form

Blueberry Pediatrics FREE Telemedicine Service for Northern Potter School District Families (made possible by an INNOVATION GRANT from the Pennsylvania Medical Society through Dr. Marlene Wust-Smith, Do No Harm PLLC)

If you are receiving this and are ALREADY signed up, have been using the Blueberry APP and have already received your entries for one of the four FABULOUS prizes, please fill in ONLY your name/email address and phone number and submit. We are trying to get to as close as 100% participation and it has been a long process!
To be eligible, at least ONE child in your household must be enrolled in the Northern Potter School District (but ALL children in your household ages 0-21 can be "seen" by a pediatrician via the app 24/7).

All costs ($100 kit and $20/month membership fee) are being paid by a generous grant provided by the Pennsylvania Medical Society via an Innovation Grant.

Your family’s Blueberry Pediatrics membership will be active through the end of 2023 (possibly longer, if we can secure the funds!)

The unique aspect of this project is that your school-aged child CAN be seen by a pediatrician (usually Dr. Wust-Smith via the Blueberry Pediatrics app) when they present to the school nurse (Mrs. Jess Cizek) during the school day with a minor complaint (one that can be safely assessed/treated in the school setting such as a sore throat, earache, rash, etc). The grant is paying for the cost of rapid strep test kits, urine dipstick "point of care" tests, and some other minor supplies.

The school nurse will ALWAYS contact the parent/guardian first for permission to treat, and you (the parent/guardian) will communicate directly with the pediatrician via "quick chat" in the app or via a phone call.

We hope for as close to 100% participation from the 300+ families in the NoPo District as we start the new school year. As a token of our appreciation (and in an effort to increase interest and participation in the grant!!) we have FOUR amazing PRIZES to be raffled when we reach the 80% goal of all registered Northern Potter families!).

To be eligible to COLLECT a prize, the winning parent/guardian MUST have an ACTIVE ACCOUNT with their child's information entered on the BLUEBERRY APP (families are not required ever to use the APP if their child is not sick and/or if they do not have any questions).

PRIZE ALERT

10 TICKET ENTRIES for FAMILIES who have already downloaded the APP
5 TICKET ENTRIES for NEW FAMILIES who sign up for the program
5 TICKET ENTRIES for REFERRING a NEW FAMILY to the program
1 EXTRA/BONUS TICKET ENTRY FOR ANYONE WHO "SHOWS US THEIR APP"

EXTRA CHANCES TO WIN!!!

1 EXTRA/BONUS TICKET for each child who has a COMPLETE profile

(Name, DOB, Picture, PCP with Fax #, Allergies, Medications, Pharmacy Information)
BRAND NEW NoPO FAMILIES USE THIS LINK: https://app.blueberrypediatrics.com/signup/NOPO/

FAMILIES WHO HAVE ALREADY SIGNED A PERMISSION SLIP USE THIS LINK:

https://app.blueberrypediatrics.com/signup/NOPO_EMAIL
MAKE SURE YOU HAVE DOWNLOADED THE MOST RECENT VERSION OF THE BLUEBERRY APP on the APPLE PLAYSTORE or GOOGLE PLAYSTORE
Our family is already on-boarded with Blueberry Pediatrics (we have our kit, we have used the app, we love it!)

YesNo
Please feel free to share some brief thoughts about your experience with Blueberry Pediatrics so far (the good, the bad and the ugly!)
Feel free to share any comments/questions you may have so we can get back to you. If you have already provided feedback in the past AND all of your information is in your APP just provide your name and email/phone number. If you have NOT received your BLUEBERRY kit please also provide your address.
PARENT/LEGAL GUARDIAN FIRST NAME and LAST NAME *

PARENTS' FIRST NAME PARENTS' LAST NAME
Address (where you would like to have your Blueberry kit mailed to)*

Street Address

Street Address Line 2

CityState

Postal / Zip Code
Email*
Phone Number*
Your preferred pharmacy
If your pharmacy is not listed PLEASE update this information in the Blueberry Pediatrics APP
General opinion of telemedicine for ANYONE in your family

Love itHave no idea what telemedicine isHate it..would rather see/talk to my own PCPBetter than the ER or Urgent CareOther
General opinion of telemedicine for CHILDREN

Love itHave no idea what telemedicine isHate it...would rather have my child see their own PCPBetter than the ER or Urgent Care if my child's own doctor can't see themIt's important that they be seen by a pediatricianOther
How many times in the past school year have any of your children been sick and/or have had to be picked up from school to be evaluated in person by their doctor (or Urgent Care/ER)?
If applicable, please comment below what having a sick schoolchild means for you and your family (do you have to leave work? Take a sick day? How far do you have to drive to pick your child up? How far away is their doctor?)
YOUR COMMENTS (if applicable)
Your CHILD(REN)'S Primary Care Physician (Pediatrician or Family Practice Physician) or PA/NP*
If "OTHER" please provide details below. INCLUDE FAX NUMBER FOR YOUR CHILD'S PCP so that we can maintain good communication with your child's "medical home"
If you have previously signed permission/signed up but have not received any further information about your membership, please indicate that in the space below. Include the email(s)/phone numbers you may have provided so that we can follow through!
Authorization
Please check the boxes below*

By submitting this form I agree to participating in this grant and I allow the Northern Potter School District to share my child’s student ID number (used to verify eligibility).I have at least one child enrolled in the Northern Potter School District.I understand that this membership/access to a pediatrician via the Blueberry Pediatrics app does NOT replace the need for an “in-person” doctor for my child(ren). I will provide the name and fax number for my child’s PCP (in the app)I agree to download the app on my own smartphone/tablet and will input all requested information about my child(ren). This includes their first name, last name, date of birth, medications, allergies, weight, height etcI understand that if my name is drawn for one of the prizes I MUST show proof that the app is downloaded on my device and that all required information has been entered (or I may have to forfeit my eligibility, in which case someone else's ticket will be drawn)I understand that my child CAN be “seen” by a Blueberry Pediatrics pediatrician (usually Dr. Wust-Smith) but ONLY with your express permission (school nurse Jess Cizek will contact you first)
Patient/Parent/Guardian Signature*

Clear
Date Signed

MonthDayYear
CHILD 1

First NameLast Name
CHILD 1's Date of Birth

MonthDayYear
Date
CHILD 2

First NameLast Name
CHILD 2's Date of Birth

MonthDayYear
Date
CHILD 3

First NameLast Name
CHILD 3's Date of Birth

MonthDayYear
Date
CHILD 4

First NameLast Name
CHILD 4's Date of Birth

MonthDayYear
Date
If you have MORE than 4 children, please list them below (name, date of birth)
Type a question
Should be Empty:

Blueberry Pediatrics FREE Telemedicine Service for Northern Potter School District Families (made possible by an INNOVATION GRANT from the Pennsylvania Medical Society through Dr. Marlene Wust-Smith, Do No Harm PLLC)

Authorization