Sagkeeng Child Wellness Check Consent Form

Sagkeeng Child Wellness Check
The Sagkeeng Health Centre will be performing some simple health screening tests on all Sagkeeng children/youth ages 4 to 18. This is a new Service that has been developed with Giigewigamig First Nation Health Authority in collaboration with Sagkeeng, Black River, Hollow Water and Bloodvein Health Centres.

These tests are to check for Chronic Diseases including Hypertension (High Blood Pressure), Diabetes and Prediabetes, Obesity, Anemia, Kidney and Liver Problems. Ages 12-18 will also be offered testing for sexually transmitted infections. (By their request only).

Step 1: Children ages 4 to 18 will have: 1) Blood Pressure 2) Height and weight 3) Skin (neck) checked at their School.

Step 2: Parents/guardians will be sent their Child’s info and need tobring their Child to the lab to complete the testing.
Consent for Child and Youth Screening:
If you would like your child/teenager tested at the school, please sign to give your consent.

If your child does not attend school & you would like for them to be screened, please contact Mike Dorie at 204-406-4467 or Facebook.
Personal Information
Your child’s full name

First NameLast Name
Your child’s school
Your child’s grade
Your child’s age
9-Digit Manitoba Health # (PHIN #)
6-Digit Manitoba Health # (MHSC #)
Your Child’s Date of Birth

MonthDayYear
Date
If your child is identified with a chronic disease, the Health Centre will inform you & refer them to a Doctor or NP.

*PHIA (patient confidentiality) and OCAP (community ownership of our own health information) protocols will be followed.
Parent or legal decision-maker to complete:
NoYes (If yes, please describe)
If yes:
NoYes (If yes, please describe)
If yes:
Height and Weight CheckBlood Pressure CheckSkin Check (Neck)Lab Tests
I do not consent
Notice: Parents will receive a follow-up package including lab forms to take your Child to the lab.

The medical file, census, vital statistics data will be reviewed, and results will be analyzed for community statistics (without patient names) The information will be owned by and shared with the four GFNHA communities and GFNHA. Information gathered about the community may be published in reports or articles or presented in public forums if consent is given, however your Child’s personal information will be kept CONFIDENTIAL.
Name of Child’s Family Physician/NP/Pediatrician and their location:
I give consent for the medical information gathered to be shared with my Child’s Physician(s).
Your name

First NameLast Name
Signature
Relationship to Child:
Date

MonthDayYear
Date
Phone Number (Home)
Please enter a valid phone number.Format: (000) 000-0000.
Phone Number (Cell)
Please enter a valid phone number.Format: (000) 000-0000.
Phone Number (Work)
Please enter a valid phone number.Format: (000) 000-0000.
Email
example@example.com
Should be Empty:

Sagkeeng Child Wellness Check

Consent for Child and Youth Screening:

Personal Information

Parent or legal decision-maker to complete:

Notice: Parents will receive a follow-up package including lab forms to take your Child to the lab.