SBHS 2025-26 Reg Pack

SECTION II: PATIENT HOUSEHOLD INCOME INFORMATION

Please view the chart below and select your family size and annual household income range from the corresponding dropdown menu (first find family size then find income range in same row)
Please select your family size from the dropdown menu*
For a family size of 1, select your annual income range from the dropdown menu
For a family size of 2, select your annual income range from the dropdown menu
For a family size of 3, select your annual income range from the dropdown menu
For a family size of 4, select your annual income range from the dropdown menu
For a family size of 5, select your annual income range from the dropdown menu
For a family size of 6, select your annual income range from the dropdown menu
For a family size of 7, select your annual income range from the dropdown menu
For a family size of 8, select your annual income range from the dropdown menu

SECTION V: FINANCIAL RESPONSIBLE PARTY INFORMATION

Should match insurance card, if applicable. Only complete this section if the responsible party is different from patient.
Name

First NameLast NamePreferred NameMiddle Initial
Social Security Number (SSN)
Date of Birth (mm/dd/yyyy)

MonthDayYear
Address

Street Address

Street Address Line 2

CityState

Zip Code
Please fill out any/all contact methods.
Cell Phone
Please enter a valid phone number.
May we leave a voicemail?

YesNoN/A
Alt. Phone
Please enter a valid phone number.
May we leave a voicemail?

YesNoN/A
Email Address
example@example.com
Preferred Language
Interpreter Needed?

YesNo
I authorize release of information regarding continuation of care and/or any payments for services. I authorize a copy of this document may be used as the original document. I certify all information provided is true and accurate to the best of my knowledge.
Patient Signature*

Clear
Date*

MonthDayYear

SECTION III: GENERAL HEALTH QUESTIONS
Do you have concerns regarding your child's physical, mental, and/or emotional development?*

YesNo
If yes, what are they?
Do you have concerns regarding your child's school performance?*

YesNo
If yes, what are they?
Is your child involved in special education classes?*

YesNo
If yes, what are they?
Do you have concerns about your child's health?*

YesNo
If no, what are your additional concerns?
SECTION IV: PRIMARY CARE PROVIDER AND PHARMACY INFORMATION
Primary Care Provider
Provider Name
Primary Care Address

Clinic Name

Street Address

CityState

Zip Code
Preferred Pharmacy Address

Pharmacy Name

Street Address

CityState

Zip Code
Any additional providers your child sees regularly?

Enter information below if applicable.
Provider 1
Provider Name
Provider Address 1

Clinic Name

Street Address

CityState

Zip Code
Provider 2
Provider Name
Provider Address 2

Clinic Name

Street Address

CityState

Zip Code
F1079 / APPROVED FOR USE / SCHOOL YEAR 2025-26

Please note that for privacy reasons, we are unable to respond via email to questions regarding specific health concerns.
Please verify that you are human*
Should be Empty:

OMAHA PUBLIC SCHOOLS