I, _________ (parent/guardian) acting on behalf of ________ (student/patient) who is suffering from a condition requiring medical, podiatric and/or dental care.
I agree to allow this care to be received. It may include routine diagnostic and medical treatment that the attending physician(s) or others of the health center medical staff consider necessary. Services could include treatment for illness or injury including over the counter medications or necessary prescriptions, well child exams, appropriate immunizations, and appropriate behavioral evaluations--unless emergency services are needed.
2. I understand that the practice of medicine and surgery is not an exact science, and that diagnosis and treatment may involve risks of injury or even death. I acknowledge that no guarantees have been made to me about the result of examination or treatment in this
3. I understand that:
a) Normally, except under emergency or extraordinary circumstances, no important procedures are performed upon a patient unless and until he or she has had an opportunity to discuss them with the physician or other health professionals to the patient's satisfaction.
b) Each patient has the right to agree or refuse to agree to any proposed procedure or therapeutic course; and
c) No patient will be involved in any research or experimental procedure without his or her full knowledge and agreement.
4. I realize that there are medical, nursing and other health care personnel at this health center who are still in training. I understand that they may be present during my care unless I request them not to be present.
5. This form has been fully explained to me, and I am satisfied, and I understand its content and significance.
6. Once the student's completed consent and history are received, PrimaryPlus can begin caring for your child for approved services during school hours. Attempts will be made to notify the parent/guardian of your child's appointment and to see if they wish to attend the visit. If no contact is made and all consents are in place, PrimaryPlus will continue the appointment as needed and contact the parent with follow-up information following the appointment including sending home a copy of the care summary.