2024-2025 SBHC Enrollment Forms

Members of Household

Allergies

List all environmental or medication allergies. Please include the level of reaction to that allergy.

Allergies List

	Name of Allergen	Severity of patient’s reaction when exposed to allergen. (mild, moderate, severe)	Does patient carry an EpiPen due to this allergy?
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2
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7

Medications

List any prescribed or over-the-counter medications. Please include vitamins, supplements, and herbs.

Medication List

Surgical History

	Type of Surgery	Date of Surgery	Which hospital/facility was the surgery done at?
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3
4
5
6

Consent For Treatment
I consent for my child to receive healthcare services provided by the State-licensed healthcare professionals of Valley Health Care, Inc. I understand that confidentiality between the patient and the healthcare provider will be ensured in specific service areas in accordance with the law, and that students will be encouraged to involve their parents or guardians in counseling and medical care decisions.

I have read and understand the services provided. By signing this form, I give consent for my child to receive services provided by the Valley Health Care, Inc. School-Based Health Center.
Signature of Parent/Guardian (or student if 18 years or older or otherwise permitted by law)*

Clear
Date*

MonthDayYear
Date

HIPAA COMPLIANT PARENTAL CONSENT FOR RELEASE OF HEALTH INFORMATION
My signature on this form allows the release of medical information that otherwise may be protected from disclosure by federal privacy law and state law.

By signing this consent, I am allowing Valley Health Care, Inc. to share the following information with the Randolph County School Nurse who is in my child's school, if necessary:

1. my child's vaccine records to show proof of vaccination of required vaccines by WV state law for school entry

2. contagious diseases that my child has tested positive for at the School-Based Health Center (Strep throat, Impetigo, Flu, COVID, etc) to help decrease spread of contagious diseases within my child's school

3. I am also consenting for Valley Health Care, Inc. to contact other providers that have examined my child and to obtain insurance information.

I understand that I do not have to allow the release of my child's medical information, and that I can change my mind at any time and revoke my authorization by writing to Valley Health Care, Inc. However, after a disclosure has been made, it cannot be revoked retroactively to cover information released prior to the revocation.
Signature of Parent/Guardian (or student if 18 years or older or otherwise permitted by law)*

Clear
Date*

MonthDayYear
Date

Well-Child Form
Childs Name
Date of Birth

MonthDayYear
Date
Parent/Guardian Name
Primary Contact Number
Secondary Contact Number
If your child does not have insurance or has limited coverage, they may benefit from our Care Connect program. Would you like more information on this program?

YesNo
Should be Empty:

	Yes	No
Anemia or Blood Disorders
Asthma
ADHD
Bladder or Kidney Infections
Allergies
Headaches/Migraines
Learning/Developmental Differences
Mental Health Issues (Anxiety, Depression, etc.)
Diabetes
Thyroid Problems
Concussion
Overweight/Obesity
High Blood Pressure
High Cholesterol or High Triglycerides
Seizures
Sleeping Issues
Bowel Problems or Reflux
Eye or Ear Problems
Heart Murmur or Heart Problems
Skin Problems (Acne, Eczema, etc.)

	Father	Mother	Brother(s)	Sister(s)	Son(s)	Daughter(s)	P. Grandmother	P. Grandfather	M. Grandmother	M. Grandfather	P. Uncle	P. Aunt	M. Uncle(s)	M. Aunt(s)
Cancer
Heart Disease
Diabetes
Stroke/TIA
High Blood Pressure
High Cholesterol or Triglycerides
Alcohol or Drug Abuse
Anxiety, Depression, or Psych Ilness
Tuberculosis
Anesthesia Complications
Genetic Disorder
Liver Disease

School-Based Health Clinic