Memphis Shelby County Patient Registration Form

Christ Community School Based Health Registration

Please fill in the form below
Student Name*

First NameLast Name
Gender*
Date of Birth*

MonthDayYear
Student Race
Student Ethnicity
Preferred Language
Student Current School
Student Current Grade
Address:*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Parent/Guardian Information
Name:*

First NameLast Name
Relationship
Contact Number*

Area CodePhone Number
Emergency Contact Number:

Area CodePhone Number
E-mail
Taking any medications, currently?*

YesNo
Please list medications
What health conditions does your student have, if any?
What allergic reactions does your student have, if any?
Do you have medical insurance?*

YesNo
Are you interested in our Sliding Fee Program? This offers discounts on medical care based on family size and income. You may be eligible even if you have insurance.Type a question

YesNo
Who is your primary care provider (choose from the drop down list)Type a question
By submitting this form, you agree to allow Christ Community Health Services to follow up with you using the number provided here by text or phone call. If you disagree, uncheck the box but this could delay our ability to follow up.As the parent/guardian of the student, I consent for Christ Community Health Services to provide the following services for my child at the school-based clinic locations or by telehealth services.
Please check all that apply:

Diagnosis and treatment of minor and acute illnessesFirst Aid of minor injuriesPhysical examinations (General, sports, pre-employment)ImmunizationsVision and hearing screeningsDiet, nutrition and weight counselling and control programsDiagnosis and treatment of sexually transmitted diseasesOther
Should be Empty:

Christ Community School Based Health Registration