Bear Care Clinic: Confidential Appointments

Your Confidential Appointment:

• Private and confidential
• No cost
• No judgment

Please complete this consent form for your confidential appointment. All of the information you add to this form and what you tell us in the clinic is private - we cannot share it with anyone outside the clinic without your permission.

Minnesota State Law allows minors (under the age of 18) to consent to certain types of services without parent or guardian permission. These services include (but are not limited to):

• Sexually transmitted infection (STI) questions, testing, and treatment
• Sexual health concern
• Pregnancy test
• Pregnancy prevention or birth control
• Drug or substance abuse concerns
• Mental Health counseling (16 years and up)

Minors who need health services outside the areas listed above will need permission from their parent or legal guardian.

In certain situations where we suspect abuse, neglect, or your health is in danger, we are required by law to involve the appropriate parties.

 

Bear Care contact:

(651) 444-6750

BearCare@RiseUpHealthClinics.org

The Bear Care Clinic is located in White Bear Lake Area High School.

5045 Division Ave., White Bear Lake, MN 55110

Park in the main lot on Division Ave. and enter MAIN ENTRANCE/DOOR A

By checking the box below, I acknowledge understanding of the following statements.

• I am able to understand facts and information.
• I understand what may happen to me as a result of my actions.
• I believe that the health services I have asked for will benefit me and are necessary for my health and well-being. 
• Involving my parent(s) or guardian(s) in this decision would be a problem for me at this point.
• I will not use health insurance for this appointment, and the clinic will pay for my services using a Health Equity Fund. [This billing information will not be shared outside the clinic.]
• I will listen to the risks and benefits of the treatment explained to me during my appointment and accept the risks and benefits of the treatment I choose.
• I will ask questions if I need more information to make a decision about my health care.

By signing this Minor Consent Form, I understand that:

• The statements above are true and represent my current situation.
• I request and consent to health services offered by the Rise Up Health Clinics. 
• Rise Up Health Clinics may use student health records to evaluate the quality of care and program effectiveness.
• Immunization information may be shared through the Minnesota Immunization Information Connection (MIIC) with healthcare providers, schools, health departments, and others authorized under law to receive it.
• If I have any questions, I will ask the clinic's health care provider.
• I also acknowledge that a copy of the NOTICE OF PRIVACY PRACTICES and PATIENTS' RIGHTS AND RESPONSIBILITIES and DATA PRIVACY INFORMATION (see final page after signature or our website) has been made available to me.
• By signing this form, I acknowledge that I have read and understood the information provided above and voluntarily consent to receive the services listed.