INSTRUCTIONS FOR COMPLETION AND SUBMISSION OF CPYB 5-WEEK SUMMER BALLET PROGRAM S HEALTH FORM PACKAGE
|
|
- Sharyl Thompson
- 6 years ago
- Views:
Transcription
1 INSTRUCTIONS FOR COMPLETION AND SUBMISSION OF CPYB 5-WEEK SUMMER BALLET PROGRAM S HEALTH FORM PACKAGE All families are required to complete and submit ALL pages of this Health Form Package for their student to CPYB by May 1, This information is required to ensure CPYB s ability to provide the best care for your student while living away from home for the 5WSBP. Directions: Step 1 Print the health form package in its entirety. Step 2 Complete the information on page 2 by providing the student name, insurance coverage information, and credit card information for emergency fees that the student would accumulate at local medical facilities during their stay in Carlisle, PA. Step 3 Please make a copy of the insured s insurance cards front and back; and add the copies as pages 8-9 of the health form packet. Step 4 Complete the information on pages 3 and 4 to provide a health care facility the medical history of your student for use in an emergency visit. Please sign, state relationship to the student, and date page 4. Step 5 NOTE: Page 5 must be completed and signed by a PHYSICIAN. A copy of a PREVIOUS PHYSICAL EXAMINATION can be used if dated AUGUST 1, 2014 OR LATER. If the student has a chronic health condition, a PLAN OF ACTION (Page 6) MUST BE PROVIDED BY THE PHYSICIAN in order to complete CPYB records to act in an emergency. Step 6 Page 7 requires a parental signature for CPYB to provide necessary evaluation, treatment or emergency care on Dickinson and CPYB properties as well as activity trips during the period of enrollment at CPYB 5-Week Summer Ballet Program. Step 7 Submit the entire health form package by either of these methods: 1) a scanned copy to info@cpyb.org or 2) mail to Central Pennsylvania Youth Ballet, ATTN: Logistics, 5 North Orange St, Suite 3, Carlisle, PA No health forms will be accepted on arrival day. All families should plan to have the package arrive by May 1, 2015, including the signed physician form and if required, the Chronic Health Condition Plan of Action. You may not arrive on campus without the health form package. CPYB s care of your student begins the moment they arrive at Dickinson College for registration check-in. 1
2 (Must be fully completed and updated yearly) Name: Birthdate - - Gender: M F First Middle Last Race (circle all that apply) Indian Asian Black White Hawaiian Hispanic Unknown Primary Language Spoken DOES THE PATIENT HAVE INSURANCE COVERAGE? YES NO Primary Insurance Policy Holder s Full Name: Relationship to student: other ather Address: Birthdate: Phone: Name of Insurance Plan: Secondary Insurance Policy Holder s Full Name: Relationship to student: other ather Address: Birthdate: Phone: Name of Insurance Plan: If more than one insurance - have you completed your coordination of benefits form for this year? Yes No Please use the following card for any Emergency Fees that the student accumulates. CPYB must have your credit card information on file in the event your insurance denies your claim at local medical facilities. The financial information in the family portal is stored offsite in an electronic vault for the School Management System but is not accessible or viewable by CPYB, the Carlisle Pediatrics Center, the Carlisle Regional Medical Center, or the Holy Spirit Health System. Credit card must be valid until at least 09/2015 Visa MasterCard Discover AMERICAN EXPRESS IS NOT ACCEPTED Card Number: Expiration Date: Name as it appears on the card: Security Code: (Three digit code on back of card) Card Billing Address: Signature: Date: CPYB requires a copy of your insurance cards, both front and back, including dental/prescription cards. Please provide copies on a separate sheet and label as page 8 CPYB does not keep your credit card information on file after the summer program has ended. Your information is shredded and disposed of. 2
3 This form must be completed and returned. The following is VERY IMPORTANT to your child s health. Please complete it ACCURATELY AND COMPLETELY. Child s full name: Birthdate - - Where was your child born? Is your child adopted or fostered? Yes No ALLERGIES NO YES If yes, explain This child has No Known Drug Allergies If you answered NO, is your child allergic to: Penicillin Cephalosporin Sulpha Macrolides Other antibiotics Name: Peanuts Milk Eggs Seafood Other foods Name: Bees/wasps Indoor allergens Outdoor allergens Animals Breed: Latex PATIENT PAST MEDICAL HISTORY NO YES If yes, explain Serious accidents or injuries Surgeries Hospitalizations What age: Chicken pox disease Frequent ear infections or sinus infections Frequent sore throats or tonsillitis Other infection illnesses Allergic rhinitis or other allergy Asthma, bronchitis, bronchiolitis, pneumonia or croup Heart problems or murmur Abdominal pain/ger Constipation requiring doctor visits Bladder or kidney infection or other urologic problem Bed-wetting (after age 5) Eye conditions /wear corrective lenses Problems with ears or hearing Chronic or recurrent skin problems acne Anemia or bleeding problem Past blood transfusion Frequent headaches Seizures, developmental delays, ADD/ADHD or other neurologic disorders Mental health concerns Orthopedic problems Diabetes Thyroid or other endocrine problems If female, have menstrual periods started? If female, any problems with periods? Use of alcohol or drugs? Emotional problems Other significant issues: 3
4 FAMILY MEDICAL HISTORY NO YES If yes, explain Nasal allergies or other allergies Asthma/lung disease Heart disease or heart condition High blood pressure High cholesterol Diabetes or other endocrine problem Cancer Anemia Bleeding disorders Epilepsy or convulsions Mental retardation or developmental disorders Neurologic disorder including ADHD/ADD Liver disease Other GI disease / disorder Kidney disease Bed-wetting (after age 10) Hearing impairment Vision impairment or eye disorder Immune problems, recurrent infections or HIV/AIDS Alcohol abuse Drug abuse Mental illness Tuberculosis Other issues: SOCIAL HISTORY NO YES If yes, explain Lives with both mother and father in same house Non-intact home give custody status Lives with: Visitation status of non-custodial parent Are there siblings? Are there pets in the home? Are there guns in the home? Are guns locked and kept separate from ammunition? Other issues: Patient s Printed Name: Is there anything else regarding your child s health that you think we should know that has not already been asked? I attest that all the medical history information is true and correct to the best of my knowledge: _ Signature Relationship to patient Date 4
5 The following information must be supplied by a Licensed Health Care Practitioner. Any changes to this form should be provided to Central Pennsylvania Youth Ballet personnel upon participant s arrival at CPYB. This information is considered invalid without the signature of a Health Care Practitioner at the bottom of this page. This form must be completed in full and signed by a Licensed Health Care Practitioner within 10 months of the start of the 5-Week Summer Ballet Program. Without submission of this form, the student WILL NOT be able to participate in the 5-Week Summer Ballet Program. : BP: Pulse: Height: Weight: General Health Information: Check all applicable boxes. Explain any positive responses below. Recent illness, injury Chest pain during/after exercise Hospitalization High blood pressure Glasses/contacts Problems with joints Orthodontic appliance Dizzy during/after exercise Explain any checked boxes: Immunizations Record: MMR#1: #2: Most recent tetanus immunization date: Hepatitis B #1: #2: #3: Varicella (or chickenpox disease): Has the student had to limit dance activities during the last 6 months due to injury? Yes No Explain: Has the student been evaluated/treated for an eating disorder, depression, anxiety or panic disorder? Yes No Explain: Use this space to provide any additional information about the student s behavior and physical, emotional, or mental health about which CPYB should be aware: Health Care Recommendations: This person is under the care of a health care provider for the following condition(s): Treatment includes (IF APPLICABLE, PLEASE USE THE PLAN OF ACTION FOR CHRONIC HEALTH NEEDS FOR USE IN THE STUDIOS AND THE DORMITORIES) Limitations on activity or dietary recommendations: I have examined the aforementioned person and find him/her to be physically, mentally and emotionally capable of participation in a rigorous and intensive summer ballet program. Signature of Licensed Health Care Provider: Date: Printed name: License #: Address: Phone: Fax: 5
6 6
7 I hereby give permission to the medical personnel selected by the Central Pennsylvania Youth Ballet director (including but not limited to physical therapists, trainers, staff of the Health Center of Dickinson College, CPYB health staff, urgent car facilities, emergency room staff and any consultants that they may deem necessary) to provide assessment, treatment, appropriate diagnostic testing or hospitalization for my child; to release any records necessary for insurance purposes and to provide necessary transportation for health care services. I agree to assume all financial responsibility for medical costs incurred by the student. It is the responsibility of students and their parents to determine whether their insurance will cover any and all services that are recommended or provided during their participation in the CPYB 5-Week Summer Ballet Program. I give permission for CPYB to contact my child s medical provider for the purpose of confirming medical conditions/treatments or obtaining additional information in order to provide appropriate care. I agree to the best of my knowledge this health history is correct and complete. A photocopy of this form shall serve in the same capacity as the original document. Date Signature of Parent, Guardian or Student (if over 18 years of age) 7
Health History and Examination Form for Children, Youth and Adults Attending Camps
Health History and Examination Form for Children, Youth and Adults Attending Camps Suggested for resident camp use. Developed and approved by American Camping Association American Academy of Pediatrics
More informationPediatric New Patient Form
Pediatric New Patient Form Internal Medicine & Pediatrics Patient Information Today's Date: Legal Name: Gender: M / F Date of Birth: Age: Race : Ethnicity: E-mail Address: Other: Home Address: Primary
More informationNURSING STUDENT HEALTH & IMMUNIZATION RECORDS
NURSING STUDENT HEALTH & IMMUNIZATION RECORDS *********************************** COMPLETE THE ATTACHED HEALTH PACKET AND SUBMIT TO THE NURSING DEPARTMENT NO LATER THAN THE ASN ORIENTATION. **************************************
More informationPatient Information. Date of Birth Sex Marital Status / / Male Female Single Married Other. Address
Patient Information Patient Information Date of Birth Sex Marital Status Male Female Single Married Other Social Security Number - - Why We Ask for Race and Ethnicity Patient Goes By: Email Address In
More informationYoung Pediatrics. Registration Form. Patient Information Patient Name Date of Birth. (Last) (First) (Middle Initial) Address Sex M F
Young Pediatrics Registration Form Provider: Dr. Young Dr. Satterly Please Print Today's Date Patient Information Patient Name Date of Birth (Last) (First) (Middle Initial) Address Sex M F City State Zip
More informationPlease bring your ID and Medical/Dental Insurance cards to all appointments PATIENT REGISTRATION PATIENT INFORMATION. Cell Phone ( ) Employer s Name
Please bring your ID and Medical/Dental Insurance cards to all appointments PATIENT REGISTRATION PATIENT INFORMATION Name Last First M.I. Social Security. Home Address Street City State Zip Mailing Address
More informationPAYMENT IS REQUIRED AT THE TIME SERVICES ARE RENDERED. THANK YOU!
PATIENT INFORMATION FORM PATIENT DATA: - - PATIENT NAME (LAST, FIRST, MIDDLE) SOCIAL SECURITY # SEX ( ) - ( ) - ADDRESS HOME PHONE NUMBER MOBILE PHONE NUMBER CITY STATE ZIP CODE OCCUPATION / / DATE OF
More information2016 Health History and Enrollment for Sam Davis Youth Camp for Youth and Adults
2016 Health History and Enrollment for Sam Davis Youth Camp for Youth and Adults Complete this form in ink answering all questions. Please print legibly The parent/guardian and camper both must sign this
More informationPatient Registration. City, State & Zip Code Date of Birth Age. Occupation: Family Physician: Married Single Other Spouse's Name
*SHAREDID-42* Date of Birth: Page 1 of 2 Patient Registration Account # Patient Name Home Telephone # Work Telephone # Social Security Number Cell Telephone # Address Patient Sex City, State & Zip Code
More informationSchool Based Health Consent for Services Grace Community Health Center, Inc.
School Based Health Consent for Services Grace Community Health Center, Inc. Please read carefully: In order for us to see your child in school based clinics, all pages of this form must be completed by
More informationJacksonville State University Lurleen B. Wallace College of Nursing and Health Sciences Health Appraisal Form
Jacksonville State University Lurleen B. Wallace College of Nursing and Health Sciences Health Appraisal Form Welcome to the Lurleen B. Wallace College of Nursing and Health Sciences at Jacksonville State
More informationZooCrew Registration Packet Summer ZooCrew
Summer ZooCrew Check the weeks you would like to sign your child(ren) up for ZooCrew: 4 & 5 year olds* Week of 7/18 In My Backyard Week of 8/1 Once Upon a Story Week of 8/15 Where the Wild Things Are 6
More informationPatient: Gender: Male Female. Mailing Address: Ethnicity: Not Hispanic or Latin Hispanic/Latin Home Phone #:
5002 Highway 39 N Bldg. A Meridian, MS 39301 Phone: 601-512-0500 Fax: 601-512-0505 Patient Information Patient: Gender: Male Female First Middle Last Primary Language: English Spanish Other Mailing Address:
More informationDodge. County. Schools
Welcome to the Dodge School Based Health Clinic. Dodge Board of Education and Dodge Connection-Communities In of Dodge, Inc. are continuing to move forward with our goal of serving the children and families
More informationNew Patient Registration Form NJR_NP_F100
New Patient Registration Form NJR_NP_F100 Patient Last Name First Name Middle Name Maiden Name Address (Street or Box) City State Zip Code Home Phone Number Cell Phone Number Work Phone Number E-Mail Patient
More informationHello and Welcome! I truly look forward to working with you and your child on the journey towards optimal health. Warmly, Amanda H.
Hello and Welcome! Attached you will find pediatric intake forms. Before your child s scheduled appointment, please fill out the forms as thoroughly as possible. I know your time is valuable and by bringing
More informationAdventure Club. Before and After School Care Enrollment Packet. Before and After School Care Mission:
Adventure Club Before and After School Care Enrollment Packet Before and After School Care Mission: Our before and after school care is designed to provide children with a safe, loving and exciting environment
More informationLAST NAME: FIRST NAME: MI: STREET ADDRESS: CITY: STATE: ZIP CODE: DOB: AGE: SEX: M F: TELEPHONE#: ( ) CELL PHONE#: ( ) SSN#: MARITAL STATUS: S M W
PATIENT REGISTRATION LAST NAME: FIRST NAME: MI: STREET ADDRESS: CITY: STATE: ZIP CODE: DOB: AGE: SEX: M F: TELEPHONE#: ( ) CELL PHONE#: ( ) SSN#: MARITAL STATUS: S M W D OTHER: SPOUSE S NAME: EMAIL ADDRESS:
More informationWabash Student Health Center
Wabash Student Health Center Information and Instructions for Completing the Student Health Record Dear Incoming Wabash Student: Welcome to Wabash College! In order to make your experience at Wabash a
More informationUSGTC Summer Camps Staff Health Form. Staff and/or Parents Please Complete Pages 1 3 & 5
USGTC Summer Camps 2017 Staff Health Form Return before arriving at camp or by July 1 to USGTC Summer Camp PO Box 4088, Tequesta, FL 33469 Email to USGTC@bellsouth.net It is a requirement of the Commonwealth
More informationPediatric Patient History
Pediatric Patient History Childs Name: Today s Date: Primary Doctor: Date of Birth: Age: Reason for visit: List all chronic medical problems: List all medication dosages and frequency taken (including
More informationPatient s Full Name DOB Age. Patient s SSN Sex: Male Female Preferred Language. Place of Birth: City State Country
Hoover Hearing Clinic A division of Hoover ENT Hoover, Alabama 35244 205-733-9694 Tel PATIENT INFORMATION ACCOUNT # DATE MD NEW UPDATE Patient s Full Name DOB Age Patient s SSN Sex: Male Female Preferred
More informationAdult Health History
Adult Health History Name: DOB: Please list medications, including: vitamins, herbs, homeopathic remedies, and nonprescription medicines on the attached medication sheet. Medical History: High blood pressure
More informationPediatric New Patient Intake Form
Name: DOB: Page 1 of 5 Pediatric New Patient Intake Form Patient Information Last Name: First Name: DOB: Home Mobile Preferred (circle) : Home / Cell Email: Gender: Primary Pediatrician: Pediatrician Address:
More informationKent State University Health Services. Medical History Form
Kent State University Health Services Medical History Form 1. This form must be returned to the Student Health Service prior to being seen at UHS. 2. This form will become a part of the Student Medical
More informationPatient Name:,, Address: Phones:,, Home Work Cell. Primary Physician: Emergency Contact: Phone#:
Patient Information Patient Name:,, Last First middle initial Address: Phones:,, Home Work Cell Sex: Female Male E-Mail: Date of Birth: / / Mo. Day Year Primary Physician: Marital Status: Single Married
More informationLast Name First Middle. Mailing Address. City State Zip Phone. Date of Birth Age Soc. Sec# Cell. Employer Work Phone
Last Name First Middle Mailing Address City State Zip Phone Date of Birth Age Soc. Sec# Cell Employer Work Phone Email Address Emergency contact Phone # Relation: Name of Primary Insurance Policy # -----
More informationSage Medical Center New Patient Forms
Sage Medical Center New Patient Forms Patient Name: DOB: Providers and Suppliers of Your Medical Care: Please list all providers and suppliers of your medical care such as primary care physicians, specialty
More informationGirl Scouts of Orange County Health History and Medical Examination Form for Minors
Girl Scouts of Orange County Health History and Medical Examination Form for Minors Health History: The more complete information you provide, the better we are able to work with your child to ensure she
More informationCAMP WASTAHI MEDICAL FORM DUE ON OR BEFORE JULY 1, 2018
1 CAMP WASTAHI MEDICAL FORM DUE ON OR BEFORE JULY 1, 2018 CHECK LIST & INSTRUCTIONS FOR COMPLETING THIS FORM: This Medical Form is required EACH YEAR for every participant of Camp Wastahi. As a requirement
More informationCamper Health Form Camp Y-Owasco
Camper Health Form Camp Y-Owasco Health History Forms must be filled out by a parent/guardian. Please complete all pages. Incomplete or unsigned forms will be returned to you. Please return the completed
More informationCollege of Sequoias Physical Therapist Assistant Program Student Health Release Form
Part A: College of Sequoias Physical Therapist Assistant Program Student Health Release Form To be completed by the Student Name: Telephone: Cell Number: Address: City: ZIP Code: Birth Date: Family Health
More informationPlease review the following list of medications and mark the ones for which you consent:
MONTGOMERY COUNTY SCHOOL HEALTH UNIT CONSENT FOR SERVICES 20 Student Name: Grade: School: The School Health Unit will provide care for all students. This includes, but is not limited to, illness/injury
More informationADULT PATIENT INFORMATION. Patient Name: Last Name First Name Address: City: State: Zip Code: Phone #: Cell Phone #: Social Security:
716 S. Goldenrod Road n 3315 Orange Blossom Trail Fax (407) 658-2536 Fax (407) 343-1907 ADULT PATIENT INFORMATION Patient Name: Last Name First Name MI Address: City: State: Zip Code: Phone #: Cell Phone
More informationWelcome to the Southeastern Urology Associates meridianemr Patient Portal
New Patients: Please register for our Portal following the instructions below and send us a Message though the New Message Message for Office Section to let us know you received this packet and are confirming
More informationWelcome to St. Bonaventure University. We are glad you re here!
Welcome to. We are glad you re here! The staff of the Center for Student Wellness in Doyle Hall welcomes you to the next step of your life: COLLEGE! We want to make sure you have the best experience possible
More informationAllergy Consultants, P.A. Visit Date: Specialist in Pediatric and Adult Allergy, Asthma, and Sinus Disease
Allergy Consultants, P.A. Visit Date: Specialist in Pediatric and Adult Allergy, Asthma, and Sinus Disease Arthur Fost, M.D. David Fost, M.D. Satya Narisety, M.D. Anthony J. Piccolo, PA-C Patient s Name
More informationDear New Patient: Sincerely, The Scheduling Staff
Dear New Patient: Welcome to Garden State Urology. The physicians in our group are board-certified, fellowship trained urologists who provide stateof-the-art care that rivals the finest academic institutions
More informationPATIENT INFORMATION Name: Date of Birth Address: City: State: Zip
PATIENT INFORMATION Name: Date of Birth Address: City: State: Zip Primary Phone ( ) Secondary Phone ( ) Other Phone ( ) SS# - - Race Ethnicity Email address Preferred language Marital Status Minor Single
More informationFax: Do not mail the forms!
Associates in Pediatric and Adult Urology The Morristown Medical Center Health Pavilion 333 Mount Hope Avenue Suite 250 Rockaway, NJ 07866 973-895-6636 Dear New Patient: Welcome to Associates in Pediatric
More informationNovember 17-19, 2017
NE District High School Youth Gathering 9th-12th grade vember 17-19, 2017 LaVista Conference Center Omaha, Nebraska $200/person Registration Deadline: October 1st (Scholarships available) Late registration
More informationMay Family Chiropractic Health Information and Health History Patient Name: Gender: Male Female
1 Health Information and Health History Patient Name: Gender: Male Female Marital Status: (Circle one) M S D W Other: Date of Birth / / Spouse Name: How many children: Patient Social Security Number: -
More informationWould you like to follow us on: Twitter Facebook Physician's Signature
PATIENT REGISTRATION INFORMATION TODAY S DATE: / / Last Name First Name MI Soc. Sec. # Date of Birth Sex Male Female Patient Address Apt. City, State, Zip Single Married Divorced Widow Home Phone Work
More informationFulcrum Orthopaedics Patient Registration Packet
Fulcrum Orthopaedics Patient Registration Packet 2 Patient Information Form 8 Consent for Use and Disclosure of Information 9 Authorization for Use and Disclosure of Protected Health Information 10 Notice
More informationTel: Fax:
Laith Farjo, M.D. Providing state of the art orthopedic care in a friendly environment Your Appointment: Time: Please complete the enclosed forms in ink and bring them with you along with your photo ID
More information4-H HEALTHY LIVING RETREAT OCTOBER 13 TH -15 TH. Learn about careers & other opportunities in the healthy living field!
Learn about careers & other opportunities in the healthy living field! Attend workshops on trending topics in Healthy Living! OCTOBER 13 TH -15 TH 4-H HEALTHY LIVING Take the 500 Mile Challenge, and participate
More informationCity. Whom may we thank for referring you to us?
CAMBRIDGE DENTAL CENTER - PATIENT REGISTRATION Date Patient's Last Name First :Kame MI Age Soc. Sec. No.: Home Work Phone: Home rujul
More informationPATIENT INFORMATION INSURANCE INFORMATION
PATIENT INFORMATION Patient Name: Date of Birth: SSN: Cell Number: Cell Phone Provider: Home Number: Work Number: Home Address: City/State: Zip: Employer: Occupation: E-Mail: Relationship Status: S M W
More information351 Osborne Road, Loudonville, New York ARWynnykiwDDS. Welcome!
351 Osborne Road, Loudonville, New York 12211 518.432.3991 518.432.3987 smile@albanydds.com ARWynnykiwDDS www.albanydds.com Welcome! When it comes to dentists, I know that you have many options. My goal
More informationName DOB / / SS# / / Street Address City/State/Zip. Home ( ) - Cell( ) - Work( ) - Emergency Contact Day Phone( ) -
Wellesley Women s Care, P.C. PPG Thank you for taking the time to complete this form. We ask that you complete this entire form once a year or when you have any NEW information. PATIENT INFORMATION (Please
More informationNC 4-H Youth Development Health History & Authorization Form
4-H Group / County: Year: (Must be updated each year) 4-H ers Name: Last Name First Name Middle Initial Birth Date / / Age as of Jan. 1 Gender: Female Male Email: Address: Street City State Zip Code Custodial
More informationNeck & Spine Patient Demographic
Neck & Spine Patient Demographic o New Patient o Return Patient o Update Account #: Physician: Last Name First Name MI: Address City State Zip Home Phone o OK to Leave Msg. Work Phone o OK to Leave Msg.
More informationACKNOWLEDGEMENT OF HIPAA PRIVACY INFORMATION CONSENT TO USE OR DISCLOSE MEDICAL INFORMATION
Patient Name (PLEASE PRINT): Date of Birth: ACKNOWLEDGEMENT OF HIPAA PRIVACY INFORMATION The & Center of Southern Oregon, PC s Notice of Privacy Practices contains information about the uses and disclosures
More information(Please Print) PATIENT INFORMATION. Sex: Male Female Home phone no: ( ) City: State: Zip: Cell phone no: ( ) Occupation: Employer: Work phone no: ( )
(Please Print) Today s date: Primary Care Physician: PATIENT INFORMATION First name: Middle: Last: Former name: Marital Status: Single Married Divorced Widowed Street address: Birthdate: SSN: Email Address:
More information**** Medical Information/ Emergency Contacts/ Insurance/ Consent ****
Arrival Departure Certification Level: **** Medical Information/ Emergency Contacts/ Insurance/ Consent **** Camper s Name: Birthdate: Age: Parent/Legal Guardian/Adult Leader Name: Day Time Phone: Evening
More informationWelcome Letter- Orchard School Clinic
Welcome Letter- Orchard School Clinic Dear Parent or Guardian: Orchard School Clinic is a school-based location of RiverStone Health Clinic. This is a collaborative effort between RiverStone Health, Billings
More informationAcademic Year Programs Medical Evaluation Form
This form is to be completed by NSLI-Y semi-finalists who selected Academic Year as any one of their duration preferences on the NSLI-Y application. NSLI-Y MEDICAL REVIEW POLICIES NSLI-Y requires a thorough
More informationHARBOR CARE HEALTH & WELLNESS CENTER Patient Intake Form Please print clearly. Please ask for assistance in completing this form if needed.
Today date: HARBOR CARE HEALTH & WELLNESS CENTER Patient Intake Form Please print clearly. Please ask for assistance in completing this form if needed. Patient Full Name: Of Birth: Street: City: Zip Code:
More information4-H Enrollment Form. Name of 4-H Group/Unit: Member Name: First Middle Last. Address: Street Address City State Zip Code
4-H Enrollment Form Name of 4-H Group/Unit: Year: Member Name: First Middle Last Address: Phone:( ) Email: County: Gender*: q Male q Female Date of Birth: Grade: School Attending: If re-enrolling in 4-H,
More information2018 Counselor College
OHIO STATE UNIVERSITY EXTENSION 2018 Counselor College Canter s Cave 4-H Camp, Jackson, Ohio March 24 th @ 1:00 p.m. - March 25 th @ 10:30 a.m. Counselor College is open to any teen, 14-18 years of age,
More informationPatient Name: Last First Middle
Wilmington Ear Nose & Throat Associates, PA Patient Information Form Patient Name: Last First Middle Mailing Address: Street Address (if different from above): City: State: Zip Code: Social Security #:
More informationALABAMA INDEPENDENT SCHOOL ASSOCIATION MEDICAL HISTORY FORM
(Please Print) ALABAMA INDEPENDENT SCHOOL ASSOCIATION MEDICAL HISTORY FORM DATE / / FULL NAME OF STUDENT BIRTHDATE / / First Middle Last AGE SEX RACE: BLACK WHITE OTHER ADDRESS PHONE ( Street City State
More informationSouthwestern College Nursing & Health Occupations Programs MEDICAL EXAMINATION FORM
Southwestern College Nursing & Health Occupations Programs MEDICAL EXAMINATION FORM TO THE PHYSICIAN: Southwestern College requires a physical examination for students enrolling in the Nursing and Health
More informationMAIN STREET MEDICAL NEW PATIENT QUESTIONNAIRE
NEW PATIENT QUESTIONNAIRE Patient Name: Date: Date of Birth: SSN: Male Female Guarantor Name: SSN: DOB: Home Phone: Cell Phone: Street Address: Apt#: City: State: Zip: Billing Address (if different): Email
More informationWITHOUT YOUR WRITTEN CONSENT, WE CAN NOT SPEAK TO ANYONE REGARDING YOUR MEDICAL CARE due to privacy laws. You have the right to list anyone you
PATIENT REGISTRATION FORM PLEASE PRINT : Referring Physician: Primary Care: Patient s Name: Last First: M.I. Address: City: State: Zip: Home Phone: Cell: Work: Email: Preferred Contact Method Race: Ethnicity:
More informationThe Home Doctor. Registration Checklist
The Home Doctor Registration Checklist All enrollees: ( ) Enrollment Form ( ) Copy of Insurance card(s) ( ) Medication List ( ) POA/Guardianship documents NOTICE Please allow two weeks for processing this
More informationGRAHAM CHIROPRACTIC CENTER, INC. BRYAN GRAHAM, DC, CCSP
New Patient Intake Form Patient Information Thank you for choosing our practice for your chiropractic needs. Please fill out this form as completely as possible. If you have any questions or concerns,
More informationSchool-Based Health Center Enrollment Packet
School-Based Health Center Enrollment Packet INTRODUCTION AND INSTRUCTIONS: This center is very unique being school based. It offers the students and community members access to medical care when it might
More informationBACK FOR ANOTHER Come and YEAR celebrate
The All Days are Happy Days summer day camp offers a week of fun, learning, and activities for the child with Attention Deficit Hyperactivity Disorder. The University of Tennessee, Boling Center for Developmental
More informationHIGHLAND MEDICAL INFORMATION FORM
HIGHLAND MEDICAL INFORMATION FORM TODAY S DATE: SESSION NAME SESSION DATE Having adequate information about your child is crucial to our ability to provide a supportive environment. We rely on you to tell
More informationHistory Form. PAST SURGICAL HISTORY Surgeries/Hospitalizations Year Complications/Problems with anesthesia
History Form Name: Date of Birth: Today's Date: Height: Weight: Date of Injury: Primary Care Physician: Address Who recommended this office? Address CHIEF COMPLAINT Why are you seeing the doctor today?
More informationMedications List. Allergies. Drug Name Dosage Directions Reason Taking
Patient Name: DOB: Medications List Allergies Please list any medications you are currently taking Drug Name Dosage Directions Reason Taking Preferred Pharmacy: Date: Location/Number: New Patient Background
More informationHOBART AND WILLIAM SMITH COLLEGES/UNION COLLEGE MEDICAL REPORT FOR STUDY ABROAD
HOBART AND WILLIAM SMITH COLLEGES/UNION COLLEGE MEDICAL REPORT FOR STUDY ABROAD Your name: Program and semester you will be abroad: INSTRUCTIONS TO THE APPLICANT: Complete Sections I through V. If you
More informationColumbia Gorge Heart Clinic 1108 June St. Appointment date/time Hood River, OR fax Physician
Columbia Gorge Heart Clinic 1108 June St. Appointment date/time Hood River, OR 97031 541-387-6125 fax 541-387-6315 Physician Welcome to the Columbia Gorge Heart Clinic. We welcome you as a patient and
More informationNORTH CAROLINA 4-H VOLUNTEER APPLICATION
NORTH CAROLINA 4-H VOLUNTEER APPLICATION PERSONAL INFORMATION First Name: Middle Name: Last Name: Suffix: Preferred Name: Mailing Address: Mailing Address 2: City: State: Zip: Gender: Male Years in 4-H:
More informationHealth & Safety Packet for Incoming Students
Health Occupations Division 707-256-7600 Health & Safety Packet for Incoming Students This packet has been designed to help Health Occupations students comply with CPR and health/physical documentation
More informationFulcrum Orthopaedics Patient Registration Packet
Fulcrum Orthopaedics Patient Registration Packet 2 Patient Information Form 9 Consent for Use and Disclosure of Information 10 Authorization for Use and Disclosure of Protected Health Information 11 Notice
More informationFamily Medicine Division. Nyree Bryant DO George R. Davis DO
Family Medicine Division Nyree Bryant DO George R. Davis DO 11/12/17 Dear New Patient, Welcome to Florida Medical Clinic! We are happy that you have made our office your choice for your medical care needs.
More informationVirginia Heartburn & Hernia Institute
Virginia Heartburn & Hernia Institute PATIENT INFORMATION FORM (Please make sure to print clearly and sign at the bottom of this page) Patient s Last Name: First: Middle Initial: Marital Status: Married
More informationMOODY BIBLE INSTITUTE HEALTH SERVICE DEPARTMENT
HEALTH SERVICE DEPARTMENT Welcome to Moody! Congratulations on your acceptance to the Moody Bible Institute! Health Service is available to assist you with health concerns you may have as a student here
More informationHelpful information before your first appointment:
Casey L. Reising, M.D. 5455 W. 86th St., Suite 210 Indianapolis, IN 46268 Office 317.306.5588 Fax 317.550.1544 www.magnificatfamilymedicine.com Thank you for choosing Magnificat Family Medicine! Helpful
More informationPatient Information: Last Name First Name MI. Address Apt/Room # City Zip. Community name (if not at home) Martial Status: S M W D
HouseCalls-MD 2998 W. Montague Ave. Suite 117 N. Charleston, SC 29418 Info@housecalls-md.com Office 843-501-2031 www.housecalls-md.com Fax 888-453-0810 Patient Information: Last Name First Name MI Gender
More informationDepartment of State Academic Exchanges Participant Medical History and Examination Form
Department of State Academic Exchanges Participant Medical History and Examination Form Having been selected to participate in a U.S. Department of State educational exchange program, you are required
More information1419 Salt Springs Road Syracuse, NY (Health Office)
1419 Salt Springs Road Syracuse, NY 13214-1301 315-445-4440 (Health Office) Dear FAMILY NURSE PRACTITIONER Student: Congratulations! As Nurse Manager of the Wellness Center I would like to welcome you
More informationPLEASE FILL OUT FORM BELOW AND THEN FAX BACK TO: ADDITIONALLY, PLEASE BRING FORM WITH YOU ON THE DAY OF YOUR SCHEDULED APPOINTMENT.
PLEASE FILL OUT FORM BELOW AND THEN FAX BACK TO: 516-354-8597 ADDITIONALLY, PLEASE BRING FORM WITH YOU ON THE DAY OF YOUR SCHEDULED APPOINTMENT. THANK YOU - 1 - NEW PATIENT MEDICAL INFORMATION Steven J.
More informationAPPLICATION PACKET All students enrolling in HCNA 1215 must complete application packet
Baton Rouge Community College Nurse Assisting (HCNA 1215) Program APPLICATION PACKET All students enrolling in HCNA 1215 must complete application packet INCOMPLETE OR LATE APPLICATIONS WILL NOT BE ACCEPTED
More informationAGE Is the student age 18 or older? (If YES, please skip to signature section below) p YES p NO
New York Summer music FeStivaL PERMISSION FORM This form must be emailed or faxed to NYSMF before your arrival. StudentName _ Festival Year AGE Is the student age 18 or older? (If YES, please skip to signature
More informationEMERGENCY CONTACT INFORMATION LIST ALL OTHER ADULTS YOU AUTHORIZE CONNECT STAFF TO RELEASE YOUR CHILD TO:
AFTER SCHOOL PROGRAM Fall Spring CHILD PERSONAL DATA SHEET Child s DOB Home Address City State Zip Gender School Enrolled in: : Employer Email : Employer Email Work APP Requested Work APP Requested EMERGENCY
More information2017 Medi-Slim Weight Loss Patient Information Form
Medi-Slim Weight Loss Patient Information Form Patient Name (Last) (First) (MI) Name you prefer to be called: Patient Address: City:_ State Zip Phone number you would prefer us to use: May we email you?
More informationCLIFTON PUBLIC SCHOOLS Student Application for Enrollment
New Address Change Re-admit Special Attention Test ESL Language This information is to be completed by school staff: Neighborhood School: CLIFTON PUBLIC SCHOOLS Student Application for Enrollment Enrolled/Magnet
More informationBETHESDA DENTAL GROUP
PLEASE COMPLETE ALLINFORMATION THAT APPLIES TO YOU - THANK YOU PATIENT LAST NAME: FIRST: INITIAL How did you hear about us? Whom may we thank for your referral? Date of Birth: Single: Married: Divorced:
More informationChild s Health History
Child s Health History Caruso Chiropractic Clinic We are pleased to welcome you to our practice. To save time and allow us to better serve you, please complete all the information required. If you have
More informationAnne C. Roulo, DC 7501 Murdoch Ave, Shrewsbury, MO, Patient Data Sheet
Anne C. Roulo, DC 7501 Murdoch Ave, Shrewsbury, MO, 63119 314.484.0690 Patient Data Sheet Date Name: Address: City: State: Zip: Social Security Number: - - Email: Home Phone: ( ) Cell Ph.: ( ) Work Ph.:
More informationYOUTH ACTIVITIES REGISTRATION FORM
YOUTH ACTIVITIES REGISTRATION FORM REGISTRATION FOR: Baseball, Basketball, Cheerleading, Flag Football, Soccer, Softball, CHILD S NAME: AGE: SEX: HEIGHT (INCHES): WEIGHT (POUNDS): D.O.B.: (YYYY/MM/DD)
More informationHealth Record Health Services 1025 North Broadway, K-254 Milwaukee, Wisconsin Phone: Fax:
For office use only: Jenzabar: / / MM DD YY (Initial) Revision date: 7/10/17 Health Record Health Services 1025 North Broadway, K-254 Milwaukee, Wisconsin 53202 Phone: 414-277-7333 Fax: 414-277-2897 Student
More informationResponsible Party Information (Information used for patient balance statements) Responsible Party Another Patient Guarantor Self
Patient Information (Please Print) Dr. Miss Mr. Mrs. Sir Patient s Name (Last) (First) (MI) Previous Name Address Line 1 City, State ZIP Home Phone Cell No. Work Phone Ext. Primary Care Provider (PCP)
More informationSawgrass Pediatrics, LLC
Child s Name of Birth Primary m m / d d / y y y y Language Race Mother s/guardian Information Mother/Guardian is Financially Responsible Yes No Mother s/guardian s Name D.O.B. m m / d d / y y y y Home
More informationJulie Gussenhoven, OD 3416 Bechelli Lane Redding, CA 96002
Julie Gussenhoven, OD OCULAR AND MEDICAL HISTORY QUESTIONNAIRE Name: M F Date: Date of Birth: Home Phone: Social Security #: Cell Phone: Address: Work Phone: City: Zip: Email: Please complete all personal
More information2018 Alexandria 4-H Summer Day Camp- Lights, Camera Cooking Registration Form
2018 Alexandria 4-H Summer Day Camp- Lights, Camera Cooking Registration Form First Name: Last Name: Address: City: Birthdate: Parent/Guardian Name: Primary Phone: State: Age as of Sept 30: Email: Alt.
More informationShingle Springs Health & Wellness Center REGISTRATION FORM
Shingle Springs Health & Wellness Center REGISTRATION FORM RPMS# Patient s Legal Name Last First Full Middle Name Sex Social Security Number Marital Status Address City State Zip Can we send mail to the
More information