Medical Consent for Treatment

Medical Consent for Treatment
PATIENT INFORMATION

Please complete the following information about your child
Child's Name*

First NameMiddle NameLast Name
Child's Date of Birth*

MonthDayYear
Date
Social Security Number*
MaleFemale
First and Last Names of ALL Parents/Guardians - Parent/Guardian #1*

First NameLast Name
Parent/Guardian #2

First NameLast Name
Parent/Guardian #3

First NameLast Name
Parent/Guardian #4

First NameLast Name
Parent/Guardian Home Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Parent/Guardian Cell Phone Number*
Please enter a valid phone number.Format: (000) 000-0000.
Parent/Guardian Work Phone Number*
Please enter a valid phone number.Format: (000) 000-0000.
Physical Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Emergency Contact Name (other than Parent/Guardian)

First NameLast Name
Emergency Contact Phone
Please enter a valid phone number.Format: (000) 000-0000.
What Pharmacy do you use?
Pharmacy city and state
Pharmacy phone number
Please enter a valid phone number.Format: (000) 000-0000.
As a Federally Qualified Health Center, Big Sandy Health Care is required to collect the following information to ensure we are providing the appropriate medical care and financial assistance, as needed.
How many people live in your home?*
What is your annual household income?*
EnglishSpanishOther
Hispanic or LatinoNon-Hispanic or Latino
WhiteBlack or African AmericanAsianNative American or Alaskan Native
Primary Care Physician Information
Who is your child's primary care physician?
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Fax Number
Please enter a valid phone number.Format: (000) 000-0000.
Would you like for your child’s visit notes to be sent to their primary care physician?
Medical Insurance Information

If you do not have medical insurance, please skip to the last question of this section
Primary Insurance Company Name:
ID Number
Group Number
Address of Policy Holder (if different than patient)

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Whose name is on the policy?

First NameLast Name
Policy Holder’s Date of Birth:

MonthDayYear
Date
Relationship to Patient:
Do you have medical insurance? *
If you do not have medical insurance, our Patient Financial Services department may contact you.
Medical History

Select all that apply
No Past Medical HistoryAsthmaAnxietyCongenital Heart DefectConcussion or Head TraumaDepressionEpilepsy/SeizuresHerniaSickle Cell AnemiaRSVMRSA Skin InfectionAllergiesAutismCardiomyopathyDiabetes Type IDiabetes Type IIGastric RefluxHigh Blood PressureSpeech DisorderMeningitisDevelopmental LearningDisorder/DelayADHDAnemiaCerebral PalsyHeart MurmurHypothyroidChicken PoxSmoking or VapingOther
Surgical History
Please include dates of procedures
Family History

Please label below with : M for Mother, F for Father, S for Sibling, and G for Grandparent.
Anxiety M, F, S, or G Asthma M, F, S, or G
Congenital Heart DiseaseM, F, S, or G   DepressionM, F, S, or G
Diabetes Type IM, F, S, or G   Diabetes Type IIM, F, S, or G
Epilepsy/SeizuresM, F, S, or G   HypothyroidismM, F, S, or G
Heart MurmurM, F, S, or G
Pacemaker  M, F, S, or G   Cardiomyopathy   M, F, S, or G
High Blood Pressure   M, F, S, or G   Sickle Cell Anemia   M, F, S, or G
High Cholesterol   M, F, S, or G   Unknown   M, F, S, or G
Unexpected or unexplained death before age 35?   M, F, S, or G
Does your child currently take any medications?*
Please list any medications with current dose (how much and how often):
Emergency medication kept at school?
Is your child allergic to any medications?*
Is your child allergic to environmental factors (bees, latex, nuts, food, etc.)?*
Please list any allergies with type of reaction (rash, lips swelling, cannot breathe, etc.):
ex. "Name of Allergen - Type of Reaction"
Please read carefully, COMPLETE FORM, SIGN, and DATE. Student should return this form to their homeroom teacher. Please notify Healthy @ School if there are any health changes or a change in guardianship.
Child's Full Name*

First NameMiddle NameLast Name
Child's Date of Birth*

MonthDayYear
Date
Social Security Number (Required)*
Child's SSN
I consent for nursing assistants, registered nurses, nurse practitioners and physicians employed by Big Sandy Health Care (BSHC) to examine, test, and treat my child, named above, onsite in his/her school or via telehealth.

RELEASE OF INFORMATION: I authorize Big Sandy Health Care to release pertinent information from my child’s record to school personnel, on a need-to-know basis, and to any insurance company or third-party payer that may be responsible for the payment of fees for the services rendered. I understand that release of information for any other reason requires me to sign an additional authorization.

PAYMENT AUTHORIZATION: If my child’s treatment may be covered by a third party payer, such as Medicaid or health insurance, I hereby authorize payment of the benefits directly to Big Sandy Health Care. I understand that I will not be held responsible for payment for services provided by Big Sandy Health Care personnel in his/her school.
Parent/Guardian Signature*

Clear
Parent/Guardian Name*

First NameLast Name
Date Signed*

MonthDayYear
Date
Patient Signature (if 18yrs or older)

Clear
Patient Name*

First NameLast Name
Date Signed*

MonthDayYear
Date
Should be Empty:

PATIENT INFORMATION

As a Federally Qualified Health Center, Big Sandy Health Care is required to collect the following information to ensure we are providing the appropriate medical care and financial assistance, as needed.

Primary Care Physician Information

Medical Insurance Information

Medical History

Family History

Please read carefully, COMPLETE FORM, SIGN, and DATE. Student should return this form to their homeroom teacher. Please notify Healthy @ School if there are any health changes or a change in guardianship.