School-Based On-site Health Consent Form
East Cleveland City school district partners with QUICKmed Urgent Care to offer School-Based Supplemental Health Services. This one form replaces many of the different permission forms required to provide these service for your child. School nursing and emergency services will still be provided as always whether or not you choose to take part in these added services. Some supplemental services may not be available at all school buildings.
Patient/ Student Name
First Name
Last Name
Patient/ Student Preferred Name
Patient/ Student Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone Number
Please enter a valid phone number.
Student Date of Birth
-
Month
-
Day
Year
Date
Grade
School Name
Sex
Male
Female
Prefer to self describe
If select "Prefer to self describe", please describe below:
Ethnicity: Hispanic/ Latino (check one)
Yes
No
Race (please select all that apply for your child):
Black or African American
White
Asian
Native Hawaiian/ Pacific Islander
American Indian/ Alaskan Native
Other
Student's Main Language
English
Spanish
Russian Turkish
Kinyarwanda
French
Arabic
Other
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Consent for Health Services Treatment
I consent to let providers participating in School-Based Supplemental Health Services perform the following services/ treatment for my child: (check each service that you want to have available for your child.)
Check each service that you want to have available for your child:
Care and treatment for injury/illness, Physical examinations (well-child or sports), Influenza (flu) immunization.
Meningococcal immunization (required for 7th & 12th graders)
Tdap immunization (required for 7th grad)
Other immunizations (age -appropriate, following the American Academy of Pediatrics immunization schedule): DTa/TD, Polio, Hepatitis B, MMR, Varicella, Hepatitis A, HPV, Pneumococcal conjugate, Hib
Well and Sick Visits
Sexually Transmitted Infection (STI/STD) testing, Education and/or treatment
Dental procedures determined medically necessary by or dentist including but not limited to Exams, X-rays, Fluoride, Cleanings, Fillings, Sealants, & Silver Diamine Fluoride.
Dental Extractions and Stainless Steel Crowns
Mental/ Behavioral Health Counseling
Eye Exam, including dilation (drops are used to make the pupil bigger), vision therapy, the fitting and dispensing of eyeglasses and corneal foreign removal (removing something from the clear, protective outer layer of the eye)
Audiology/ Hearing screening and evaluation
By signing this consent for health services treatment, I agree to the terms and conditions regarding authorization to release information and assignment of insurance benefits as explained in this consent form. I also acknowledge that I have received information about how to receive notice of privacy practice as explained in this consent. I also have received and understand available services as described in the School-Based Supplemental Health services information for parents & students handout which is available on the school district website.
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Privacy Practices & Authorizations to Release Information
I understand that the healthcare organization will not discuss my medical care or billing information with anyone not listed on this consent. Below please list people that we may release information to.
Name
First Name
Last Name
Relationship to the Student
Name
First Name
Last Name
Relationship to Student
Name
First Name
Last Name
Relationship to Student
Name
First Name
Last Name
Relationship to Student
If student/patient is less than 18 years old:
Parent/ Guardian Name
First Name
Last Name
Parent/ Guardian Signature
Date
-
Month
-
Day
Year
Date
Phone Number
Please enter a valid phone number.
If student/patient is 18 years or older:
Student/ Patient Name
First Name
Last Name
Student/ Patient Signature
Date
-
Month
-
Day
Year
Date
Phone Number
Please enter a valid phone number.
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Patient Registration Form
complete all sections
Patient/ Student Name
First Name
Last Name
Social Security Number
Sex
Email
example@example.com
Please check which insurance carrier covers you child. If you don't think your child has insurance, most school-based supplemental health services are provided at no cost to families whether or not a student has insurance or the ability for their insurance to pay.
Medicaid Managed Care Plans
Managed Care ID#:
Check your plan below:
Buckeye Health Plan
Caresource
Paramount Advantage Medicaid
Molina Healthcare
United Healthcare
Ohio Medicaid
Ohio Medicaid #
Private Insurance (Other than Medicaid)
Insurance Company
Policy Holder Name
First Name
Last Name
Relationship to the Student
Policy Holder Date of Birth
-
Month
-
Day
Year
Date
Effective Date
-
Month
-
Day
Year
Date
Co-Pay amount ($)
Policy Number
Secondary Insurance
Insurance Company Name
Policy Holder Name
First Name
Last Name
Relationship to the Student
Policy Holder Date of Birth
-
Month
-
Day
Year
Date
Effective Date
-
Month
-
Day
Year
Date
Co-Pay amount ($)
Policy Number
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New Patient History Form
Primary Care Provider:
Provider Location (city/town):
Other Provider:
Other Provider Location (city/town):
Seen by other providers for:
Dentist
Dentist Location (city/town):
Preferred Pharmacy:
Pharmacy Location (city/town):
Does your child have any allergies?
Allergies:
Describe reaction:
Allergies since birth:
Describe reaction of allergies since birth:
Family History
Does anyone at home smoke or vape?
Yes
No
Does smoking or vaping occur indoors?
Yes
No
Does smoking or vaping occur outdoors?
Yes
No
Date of your child's last physical or well-child exam?
-
Month
-
Day
Year
Date
My child has NOT had a physical or well-child exam in the last 12 months.
True
Please list below all medical problems each family member has had:
Mother medical Problems
Father Medical Problems
Grandmother
Grandmother
Mom Side
Dad Side
Grandfather
Grandfather
Mom Side
Dad Side
Brother
Sister
Check each item that is a medical problem or concern (if not checked that informs the healthcare provider there is no medical concern in that area).
Chicken Pox Disease
Dizziness/ fainting/ passing out
Psychological or mood problem
Developmental problems
Surgery or admitted to the hospital in the last year
Heart problem
Sickle Cell Disease
Immune system problem
Clotting disorder
Blood disorder
Type 1 Diabetes
Type 2 Diabetes
Endocrine disorder
History of Guillain-Barre Syndrome
Seizures (Epilepsy)
Brain or nervous system problem
Asthma
Cystic Fibrosis
Lung or breathing problem
Liver disease
GI or stomach problem
Kidney disease
Bladder or urinary problem
Pregnant
Other
Name of person completing this form
First Name
Last Name
Today's Date
-
Month
-
Day
Year
Date
Signature
Relationship to child
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Billing Agreement
I am aware that it is my responsibility as the patient to give a copy of my insurance information to QUICKmed Urgent Care, LLC. QUICKmed will work with the uninsured to obtain access to care. I am aware that my co-pay/ nominal fee is my responsibility. I may pay cash, check, or credit card. I am aware that I will only receive (2) statements and (1) past due statement (a total of 3 statements). I authorize payment directly to QUICKmed Urgent Care and/or the physicians or their designees of the benefits herein specified and otherwise payable to me but not to exceed the regular charges. My signature, or that of my authorized representative, indicates that I have read, understand and agree the above conditions and this consent for care at QUICKmed UC supersedes any other financial consent that may have been signed.
Signature of Patient/ Student/ Legal Representative/ Agent
Relationship to Patient/ Student
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