Mobile Health Patient Registration Form

Medical Associates Plus

Mobile Health Patient Registration Form
Child's Legal Name*

First NameMiddle InitalLast Name
Date of Birth*

MonthDayYear
Age*
Gender*

MaleFemale
Date*

MonthDayYear
Date
Please Select School Level*

Elementary SchoolMiddle SchoolHigh SchoolMagnet SchoolSpecial School
Elementary School
Middle School
High School
Magnet School
Special School
County*
Grade*
Teacher's Name*

Consent for Treatment
Do you consent to Dental treatment?*

YesNo
I am the parent/legal guardian of the minor child listed above. I consent to my child receiving Dental treatment, and allow the school nurse and Dental provider to view Dental records. I give Medical Associates Plus permission to treat my child and I have seen HIPAA right documentation.

Clear
Do you consent to Medical treatment?*

YesNo
I am the parent/legal guardian of the minor child listed above. I consent to my child receiving Medical treatment, and allow the school nurse and Dental provider to view Medical records. I give Medical Associates Plus permission to treat my child and I have seen HIPAA right documentation.

Clear
Should be Empty:

Medical Associates Plus