School Link Health Services Clinical Form

School Link Health Services Clinical Form

Student Information
Student Information
Name of the school your student attends:*
Grade of Student*
Student/Patient Name:*
(First, Middle, Last)
Student Preferred Name:
Student Date of Birth:*

MonthDayYear
Date
Phone Number:*
Please enter a valid phone number.
Street Address, City, State and Zip:*
Sex:*

MaleFemaleOther
Ethnicity: Hispanic/Latino*

YesNo
Race (Please check all that apply for the student):*

Black or African AmericanWhiteAsianNative Hawaiian/Pacific IslanderAmerican Indian/Alaskan NativeOther
Student Main Language:*

EnglishSpanishFrenchArabicOther
Parent/Guardian Info
Parent/Legal Guardian Name:*
Guardian DOB:*

MonthDayYear
Date
Relationship to Child:*
Guardian Phone Number *
It is very important that we have a current number to reach you while your child is being seen with MVHC. If your phone number ever changes, please notify the school as soon as possible.
Does the student have Health Insurance?

YesNoUnsure (please explain)
Primary Insurance:
Managed Care ID # or Ohio Medicaid #
Private Insurance (if other than Medicaid:)
Subscriber or Member ID:
Name of person who carries insurance:
Date of Birth:

MonthDayYear
(Of person who carries the insurance.)
Phone number on Insurance card:
Please enter a valid phone number.
Health History

To be completed by parent/legal guardian
Primary Care Provider:
Most Recent Visit:
Dentist:
Most Recent Visit:
Eye Doctor:
Most Recent Visit:
Does the child wear glasses?*

YESNO
Preferred Pharmacy:
Please list all medications the student is currently taking.
Leave blank if none.
Please list anything the student is allergic to, along with a brief description of the reaction.
Leave blank if none.

Medical History and Health Concerns

	YES	NO
Chicken Pox
Dizziness/fainting/passing out
Psychological or mood problems
Development problems
Heart Problems (or family history of)
Sickle Cell Disease
Immune System Problem
Clotting disorder or hemophilia
Other blood disorder
Diabetes
History of Abuse
History of Guillain-Barre Syndrome
Seizures
Brain or nervous system problem
Asthma
Cystic Fibrosis
Other Lung or Breathing problems
Liver Disease
Other GI or stomach problems
Kidney Disease

Please explain any medical problems marked as YES above, or any other problems you would like to mention.
Consent to Treat Student

Please complete and sign all fields below.
PRIMARY CARE SERVICES:*

YES, I consent for my child to receive NON-EMERGENT MEDICAL CARE including routine well child care* (includes work, daycare and sports physicals) appropriate immunizations, and treatment for illness or injury including over the counter and prescription medications and confidential care.** (*Note: well child care includes vision and hearing screenings, urine and blood tests, immunizations as needed and an external genital exam when appropriate). (**Note: MVHC will always encourage patients to discuss health issues with their trusted guardians. However, per State law, MVHC providers cannot discuss certain topics if the patient has requested confidentiality. These topics include mental health, substance abuse and sexual health.)NO, I do not wish for my child to receive MEDICAL CARE with the school health program.
DENTAL SERVICES:*

YES, I consent for my child to receive DENTAL SERVICES at the school health program including preventive care, dental examinations, x-rays, sealants, fillings, local anesthesia, tooth removal and root canals if necessary. Sealants and other preventable procedures will be provided at school. (Treatment plan will be approved with parents/guardians prior to starting).NO, I do not wish for my child to receive DENTAL SERVICES with the school health program.
BEHAVIORAL HEALTH SERVICES:*

YES, I consent for my child to receive BEHAVIORAL HEALTH SERVICES at the school health program (Treatment plan will be approved with parents/guardians prior to starting).NO, I do not wish for my child to receive BEHAVIORAL HEALTH SERVICES with the school health program.
TRANSPORTATION:*

YES, I consent for my child to be TRANSPORTED to and from medical, dental or behavioral health services at the school health program. I, the parent or guardian of above-named student, release MVHC, its Board Members, employees and authorized agents and representatives and the school district, its Board Members, administrators, employees and authorized agents and representatives from any and all liability related to personal injury or damage resulting from the transportation of my student to and from health services.NO, I do not wish for my child to be TRANSPORTED to and from the school health program. I understand that I, therefore, am responsible for transporting my child to all SLHC appointments.
By signing this consent, I acknowledge and assert that I am a parent or legal guardian of the student/patient named above, and I agree to the terms and conditions regarding the Authorization to Release Information and Assignment of Insurance Benefits as explained in this consent. I also acknowledge that I have received a copy of the Notice of Privacy Practices form. I understand
that I will be notified of any services my child receives, as well as any abnormal findings and/or further treatment recommendations. I hereby authorize MVHC and its personnel to deliver routine medical/dental care to my child listed above as
may be deemed necessary or advisable in the diagnosis and treatment of my child. Routine medical and dental care and interventions may include, but not limited to: medical evaluation, dental health, physical exam, routine immunizations, injections,
x-rays, lab work (examples: throat or nasal swabs, blood draws, urine catheterizations, wart treatment with liquid nitrogen, minor burns and minor suturing of lacerations.) I consent that MVHC can exchange information with the patient’s school nurse. My child’s records are protected and can only be
accessed by authorized users with restricted access. I also understand I should contact the school nurse if I have questions. I understand this consent will remain valid for the time the student is enrolled in this school district unless revoked by me in writing. It is my responsibility to notify the school nurse of all updates or changes to my child’s health condition(s), immunization records or insurance coverage.
Insurance or other health care coverage programs are billed whenever possible to help cover the cost of care. I give MVHC the right to submit claims/medical information for reimbursement under any private health insurance policy, Medicare, Medicaid or any other programs that I identify for which a benefit may be available to pay for services provided to my child through School Link Health Services.
I have read, understand and give my consent as stipulated above. My signature means that I have read this form and /or have had it read to me and explained in the language that I can understand. If I am the guardian of the person a copy of my letters of guardianship are attached.
Signature of Parent/Legal Guardian:*

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Parent/Legal Guardian's Printed Name:*
Date:*

MonthDayYear
Date
Patient's Signature (if 18 or older):

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Patient's Printed Name:
Date:

MonthDayYear
Date
Should be Empty:

School Link Health Services Clinical Form

Student Information

Parent/Guardian Info

Health History

Consent to Treat Student