If you would like your child to participate in the Life Health Center School Wellness Program, please complete pages 1-5.
|
|
- Valerie White
- 6 years ago
- Views:
Transcription
1 If you would like your child to participate in the Life Health Center School Wellness Program, please complete pages 1-5. Student Name of Birth Sex: Male Female Address Street City State Zip Grade Room School Teacher What is your child s ethnic background? White/Non-Hispanic Hispanic: Mexican Puerto-Rican Cuban Dominican Other Black/African-American Middle Eastern or African American Indian Asian/Pacific Islander Multi-racial Other It is the Wellness Center's philosophy that the doctor should speak to the parent/guardian in order to provide the best possible care to the child. What is the best way to talk to you during school hours? Name Home phone number Cell phone number Work number address Best Language? Parent #1 Parent #2 English Spanish Other English Spanish Other
2 Please tell us about your child s health: Does your child have a regular doctor? Yes No Doctor s Name Doctor s Phone number Is your child allergic to penicillin? Don t know Is your child allergic to any other medicine? Don t know Is your child allergic to any food? Don t know Please list all the other medicines and foods your child is allergic to: Please list any medicines that your child takes every day: (please add more paper if needed) Name of Medicine How much What time does your child take the medicine Does your child have any of these medical problems (please check)? Asthma Emergency plan at school? Diabetes Emergency plan at school? Epilepsy/Seizures Emergency plan at school? Food allergy Emergency plan at school? ADHD Autism Eczema Sickle Cell Disease Obesity Emotional or Behavioral problems? None Yes Other medical condition(s)? None Yes Does your child wear glasses? No Yes of last eye exam? Is there anything else you would like us to know about your child?
3 CONSENT FORM I give permission for my child to be evaluated and treated at the Life Health School Wellness Eisenberg. Please check each box below to show that you understand: I understand that: You will call me every time that you see my child. If you cannot reach me, you will treat my child and call me later to review the care. If my child has a lab test and has private insurance, I might get a bill from the laboratory. If my child has Medicaid or no insurance, I will not get any bill. The Life Health Center School Wellness Program may use telemedicine (video) to provide mental and medical health services. If video is used, there will be no recording of the video. This is the list of services that we offer. If you do NOT want your child to get any one of these services, please cross it off the list. If you are okay with all these services, please check this box: Physical Health Behavioral/Emotional Health Lab Tests Evaluation and treatment of minor illness or Evaluation for emotional Blood test injury problems Throat culture Flu vaccine Individual therapy Urine test Other vaccines that my child needs Group therapy Vision screening (including eye glasses) Family therapy General check-ups Screening for medical problems What is your child s health insurance? None Medicaid Private Insurance Carrier Policy Number Group Number Policy Holder Social Security # of Birth EMERGENCY CONTACT INFORMATION Name: Relationship to Child: Phone Number: Name: Relationship to Child: Phone Number:
4 Notice of Privacy Practices The Life Health School Wellness Center (LHSWC) operates with money from the state of Delaware and from insurance. The law requires that certain LHSWC staff provides specific patient information to DPH for certain reasons: To measure disease activity in Delaware and the United States To prevent or control disease or injury in Delaware and the United States Information that will be reported includes: sexually transmitted disease, laboratory tests about reportable diseases (some infections), deaths, adverse medication reactions, child abuse or neglect Information about services that your child receives will also be shared with your child s health insurance. You can get a copy of your child s records by: HEALTH INSURANCE PORTABILITY AND ACCOUNTABILITY ACT (HIPAA) The Life Health School Wellness Program must follow the HIPAA Privacy Rules. By law we are required to give you with a copy of this Notice of Privacy Practices. By signing below I understand that if I have any questions I may call the Wellness Center Coordinator at for more information before I sign this authorization. Name of Parent/Legal Guardian ACKNOWLEGEMENT OF HIPAA & GENERAL POLICIES I have received a copy of the following: HIPAA Notice of Privacy Practices Counseling Practice Policies and Processes Parent/Guardian Signature
5 RELEASE OF INFORMATION Please sign this form if you would like us to get and share medical information (for example, vaccine records and medicines) with your child s doctors. We believe this is very important so we can provide the best possible care. I, (Parent/Guardian), on behalf of (Child s name) give my permission for The Life Health Center staff to give my child s medical records to get my child s medical records from Please list all the doctors that you would like us to share information with: Doctor s Name Doctor s Address Doctor s Phone Number I understand that I do not have to sign this form for my child to receive care at the Life Health School Wellness Program. I understand that if I do not sign this form, it might be hard for the doctors to have all the information needed to provide the best possible care. This permission will only be good for 365 from the signed consent. I understand that I can cancel this permission at any time by writing a letter to The Life Health School Wellness Program at Eisenberg. I can send the letter by or by mail to the address below. I understand that the staff may share information in any way that is needed (paper, fax, , telephone). If I prefer a different way to share information, then I will write a letter to the Life Health School Wellness Program. I understand that the Life Health School Wellness Program cannot share any information about my child with anyone that I have not listed on this form.
VETERINARY & BIOMEDICAL SCIENCES SUMMER CAMP-2018 REGISTRATION FORM
1 VETERINARY & BIOMEDICAL SCIENCES SUMMER CAMP-2018 REGISTRATION FORM When: Residential camp: June 24 (Sunday)-June 29 (Friday), 2018 Commuters: June 25 (Monday)-June 29, 2018 In order to get personal
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 informationSchool-Based Health Center William Penn High School 713 E. Basin Road New Castle, DE Phone: Fax:
School-Based Health Center William Penn High School 713 E. Basin Road New Castle, DE 19720 Phone: 324 5740 Fax: 324 5745 Dear Parents/Guardians: The William Penn School Based Health Center (SBHC) is a
More informationSchool-Based Health Center Wilmington Charter/Cab Calloway High Schools 100 N. Dupont Road Wilmington, DE Phone: Fax:
Dear Parents/Guardians: School-Based Health Center Wilmington Charter/Cab Calloway High Schools 100 N. Dupont Road Wilmington, DE 19807 Phone: 651-2100 Fax: 651-2111 The Wilmington Charter/Cab Calloway
More informationColumbia Medical Practice- Pediatrics Ken Klebanow M.D. and Associates
HOWARD COUNTY HEALTH DEPARTMENT SCHOOL-BASED WELLNESS CENTERS PROGRAM TELEMEDICINE SERVICES A partnership between the Howard County Health Department and the Howard County Public School System What is
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 informationHale Ola Kino Maika i
We ve teamed up to make it easier for students to access healthcare in their school! Together, we are your School-Based Health Center! Waianae High School (WHS) is proud to partner with Waianae Coast Comprehensive
More informationIf you require films or CD, kindly give us 48 hour notice or make technologist aware at the time of your study.
A Note to Our Patient: Your physician will be receiving a copy of your results via fax within two business days. Please contact your physician to go over your results and to obtain a copy of your report.
More informationPATIENT REGISTRATION FORM PARENTAL MEDICAL CONSENT FORM FOR A MINOR CHILD
PATIENT REGISTRATION FORM PARENTAL MEDICAL CONSENT FORM FOR A MINOR CHILD General Consent for Treatment I have the legal right to consent to medical and surgical treatment because (a) I am the patient
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 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 informationNew Patient Paperwork
Your Vision Is Our Focus New Patient Paperwork Dear Patient, Please fill out all of the following pages, and bring them with you to your scheduled appointment time. If you have questions regarding your
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 information1.2 ADULT CLIENT INTAKE FORM: Client Information
1.2 ADULT CLIENT INTAKE FORM: Client Information FOR OFFICIAL USE ONLY: Client Number Effective Insurance No OH No CLIENT INFORMATION Client name of significant other CHILDREN INFORMATION of birth of birth
More informationThe Children's Clinic Patient Information Form
The Children's Clinic Patient Information Form Patient Name: Patient Demographics of Birth: Social Security #: Mother's Name: Parent Demographics Maiden Name: Address: City/Zip: Home Phone #: Alternate
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 information2017 VolunTeen Application. Fort Belvoir Community Hospital
Page1 2017 VolunTeen Application Thank you for your interest in participating in the 2017 Summer VolunTeen Program! The American Red Cross got its start serving the United States Armed Forces and now you
More informationAdditionally, the parent or legal guardian must provide the following documents upon registration of a new student:
Montgomery County Public Schools requires several documents upon registration of a new student. Below is a list of documents which may be downloaded and reviewed and/or completed by the parent or legal
More informationMICHELE S. GREEN, M.D.
MICHELE S. GREEN, M.D. Name Last First Middle initial Address Number Street Apt# City, State Zip Home Cell Email Please Circle: Preferred Contact Number Home Cell Work Single Married Divorced Widowed Male
More informationClient Registration Form
Client Registration Form Today s Date / / CLIENT INFORMATION (PLEASE PRESENT YOUR PHOTO IDENTIFICATION AND INSURANCE CARD WITH THIS PAPERWORK) Mr. Ms. Mrs. Legal Name: First Middle Last Suffix (Jr, Sr,
More informationCITY OF DOVER POLICE DEPARTMENT APPLICATION FOR POLICE OFFICER
CITY OF DOVER POLICE DEPARTMENT APPLICATION FOR POLICE OFFICER DO NOT WRITE IN THIS SPACE DATE RECEIVED PHYSICAL ABILITY WRITTEN EXAMINATION ORAL INTERVIEW BACKGROUND MEDICAL EXAM PSYCHOLOGICAL EXAM DISQUALIFICATION
More informationPatient s Legal Name: Preferred Name: First Middle Last
Douglas County Dental Clinic Patient Registration Revised August 2016 We REQUIRE A Parent, Guardian, Or Other Legally Responsible Party To Complete & Sign all forms. Please provide a photo ID, Proof of
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 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 informationChoptank Community Health System Caroline County School Based Health Centers Healthy Children Are Better Learners MEDICAL
Choptank Community Health System Caroline County School Based Health Centers Healthy Children Are Better Learners MEDICAL Dear Parent/Guardian: As a student in the Caroline County Public School system,
More informationRe-Vita -Life. Sub-dermal Bio-identical Pellets
Re-Vita -Life Sub-dermal Bio-identical Pellets Welcome and thank you for inquiring about Re-Vita-Life Bio-identical hormone replacement therapy. We have included a new patient information packet which
More informationSchool Manual Statewide Vision Program School Year
601 Southwest 8 th Avenue Phone: (305) 856-9830 Fax: (305) 856-9840 School Manual 2011-2012 School Year Approved by: Ed Largespada, CFO Signature: Date: Phone: (305) 856-9830 / 1(888) 996-9847 Fax: (305)
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 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 informationPATIENT REGISTRATION FORM (ecw)
PATIENT INFORMATION PATIENT REGISTRATION FORM (ecw) (Please print) Patient s Name: (Last) (First) (MI) Address: City, State, Zip: Home: Cell: Work: E-Mail Address: DOB: Sex: Female Male Transgender Race:
More informationDear Kaniksu Patient,
Dear Kaniksu Patient, Welcome to Kaniksu Health Services (KHS), a Community Health Center that provides quality and affordable medical, pediatric, dental, behavioral health and veteran care, regardless
More informationMR #: Patient Name: Page: 1 of 4 PROGRESSIVE PHYSICAL THERAPY PATIENT DATA SHEET. May we send you text messages relating to your care with us?
MR #: Patient Name: Page: 1 of 4 PROGRESSIVE PHYSICAL THERAPY PATIENT DATA SHEET First: MI: Last: of Birth: Age: Gender: Male Female Mailing Address: Physical Address: May we send you text messages relating
More informationPEDIATRIC CENTER FOR WELLNESS, P.C. CRYSTAL B. HOOD, M.D KLONDIKE RD SW SUITE 205 CONYERS, GA TELEPHONE FAX
PEDIATRIC CENTER FOR WELLNESS, P.C. CRYSTAL B. HOOD, M.D. 1506 KLONDIKE RD SW SUITE 205 CONYERS, GA 30094 678-750-4000 TELEPHONE 678-750-4005 FAX www.pcfwellness.com Dear Family, We are excited to welcome
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 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 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 informationMAIN STREET RADIOLOGY
MAIN STREET RADIOLOGY PATIENT REGISTRATION FORM **OFFICE USE ONLY** TODAY S DATE: MR#: LAST NAME: FIRST NAME: ADDRESS: APT: CITY: STATE: ZIP CODE: HOME PHONE #: ( ) - CELL PHONE#: ( ) - DATE OF BIRTH:
More informationAPPLICATION. Name (Last, First, MI): Address: City, State, & Zip Code: Home Telephone: Cell Telephone: Date of Birth: / /
Girls in Engineering Academy (GEA) July 10 August 4, 2017 APPLICATION A Summer Pre-Engineering Program for Middle School Girls Please print or type all information. Additional sheets may be attached if
More informationNAME SS# ADDRESS CITY STATE ZIP. TELEPHONE (home) (business) Cell SEX M F BIRTH DATE PLACE OFBIRTH RACE ETHNICITY LANGUAGE
REGISTRATION (please print) PATIENT INFORMATION DATE: NAME SS# ADDRESS CITY STATE ZIP TELEPHONE (home) (business) Cell Email SEX M F BIRTH DATE PLACE OFBIRTH RACE ETHNICITY LANGUAGE MOTHER'S FIRST NAME
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 informationRETURNING Student Information Update
Today s Date: RETURNING Student Information Update OFFICE USE ONLY School # Student # Grade Level Teacher Student Legal Name (first, middle, last) Suffix (Jr., Sr., II, lii, IV, V) Student Date of Birth
More informationUNIVERSAL CHILD HEALTH RECORD
UNIVERSAL CHILD HEALTH RECORD Endorsed by: SECTION I - TO BE COMPLETED BY PARENT(S) Child s Name (Last) (First) Gender Does Child Have Health Insurance? Yes No Male If Yes, Name of Child's Health Insurance
More informationBack-Up Care Advantage Program Registration Materials
Registration Materials Dear Parent, Welcome to the Back-Up Care Advantage Program! An important part of preparing for a day of back-up care is ensuring that your care provider will have the information
More informationCAMP CONNECT CHILD/TEEN APPLICATION
CAMP CONNECT - 2018 CHILD/TEEN APPLICATION Please check which date you would like your child to attend: June 25-28 August 6-9 of Application: Camper s Name: (Last) (First) (Middle) Home Address: City:
More informationALFRED ALINGU, MD INTERNAL MEDICINE
Name Date of Birth Social Security Number Marital Status Address City State Zip Code Home Phone Cell Phone E-mail Address Pharmacy Name Pharmacy Phone Number Emergency Contact Phone Number Relationship
More informationINFORMED CONSENT FOR TREATMENT
INFORMED CONSENT FOR TREATMENT I (name of patient), agree and consent to participate in behavioral health care services offered and provided at/by Children s Respite Care Center, a behavioral health care
More informationPATIENT INFORMATION Please Print
PATIENT INFORMATION Please Print DATE Patient s Last Name First Name Middle Name Suffix Gender: q Male q Female Social Security Number of Birth Race Ethnic Group: q Hispanic q Non-Hispanic q Unknown Preferred
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 informationFamily Care Health Centers
Family Care Health Centers New/Established Patient Information (Please Print) Account # Date: Circle One: New Patient or Established Patient Last: First: M.I. Date of Birth: Address: City: State: Zip:
More informationHEALTH HISTORY QUESTIONNAIRE
Patient Name: of Birth: HEALTH HISTORY QUESTIONNAIRE Primary Care Physician: Other physicians you currently see: Emergency Phone #: Contact Person/Relationship: Reason for the Visit: Please list your medications
More informationWelcome Baby Prenatal Intake
Outreach Specialist: Welcome Baby Prenatal Intake Date: / / Length of visit: hour(s) minute(s) Attempted call #1: (date) Attempted call #2: (date) Attempted call #3: (date) Client name: DOB: / / Home address:
More informationThank you for choosing Oakland Medical Center as your Patient-Centered Medical Home
Thank you for choosing Oakland Medical Center as your Patient-Centered Medical Home We ask that you complete the enclosed paperwork and bring it with you at the time of your appointment. We also ask that
More informationMiddle Initial: Street Address: City: Date of Birth: Age: Marital Status: Occupation: Employer: Name of Spouse: Emergency Contact:
SALT LAKE EYE ASSOCIATES, LLC (801) 281-2020 1025 E 3300 S, SLC, Utah * Patient Information Sheet First Name: Last Name: Middle Initial: Referred By Family Doctor EMAIL Street Address: City: State: Zip:
More informationPATIENT S NAME: LAST NAME: FIRST NAME: MI: DOB: MARRIED: SINGLE: SOCIAL SECURITY: HOME ADDRESS: APT# CITY: STATE: ZIP: CELLULAR PHONE:
5056 THOROUGHBRED LANE BRENTWOOD, TN 37027 TODAY S DATE: PHONE: 615-373-3337 FAX: 615-373-3782 PATIENT S NAME: DATE OF BIRTH: M F RESPONSIBLE PARTY/GUARANTOR INFORMATION LAST NAME: FIRST NAME: MI: DOB:
More informationAffordable Concierge New Patient Registration
Affordable Concierge New Patient Registration Patient Information Last name: First name: MI: DOB: [ ] Male [ ] Female Home address: City: State: Zip: Billing address: [ ] Same as home City: State: Zip:
More informationMembership Referral Application Please print clearly in pen
Membership Referral Application Please print clearly in pen 82 Brigham Street, Marlborough, MA 01752 Tel. (508) 485-5051 x230 www.employmentoptions.org Fax. (508) 485-8807 attn. Pat Macomber E-Mail: pmacomber@employmentoptions.org
More informationClient Information Form
Client Information Form Please read and complete all information requested. Date: Name: Address: City, State and Zip: Social Security Number: Home Phone: Work Phone: Cell Phone: E-mail: If client is a
More informationPatient Registration Form
Padma Sripada MD, Columbia Internal Medicine 2500 Pond View, Suite 202 Castleton on Hudson, NY 12033 Phone: 518-391-2889 Date: Patient Registration Form First Name Middle Last Name... Sex: M F Preferred
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 informationX Name of Patient (Please Print) X Signature of Patient (or Parent/Legal Guardian) X Name of Parent/Legal Guardian (Please Print)
In Office Policies Identification - For the protection of our patients, and to reduce medical identity theft, all patients are required to present a valid insurance ID card and/or driver s license at the
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 informationSchool Based Health Services Consent Form
MRN: PCP: Teacher: Grade: School Based Health Services Consent Form Before your child sees a provider, we are asking you to authorize medical and/ or dental treatment. We will work with you to improve
More informationPlanned Respite Referral Application
Planned Respite Referral Application White Plains, NY 10605 (914) 948-4993 or (914) 564-3749 FAX: (914) 813-4364 Dear Applicant: Thank you for your interest in Planned Respite. Planned Respite is a short-term
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 informationRETURNING STUDENT INFORMATION UPDATE
ST. FRANCIS CATHOLIC SCHOOL Student Information Date: RETURNING STUDENT INFORMATION UPDATE Student Name Last First Middle I Nickname Birth Date Gender Grade Entering Birth Country Birth City Birth State
More informationSCHOOL-BASED HEALTH CENTERS Consent for Services Information
SCHOOL-BASED HEALTH CENTERS Consent for Services Information The School-Based Health Centers are a joint effort of Optimus Health Care, Southwest Community Health Centers and the State of Connecticut,
More informationChristopher I. Zoumalan, M.D., Inc. Aesthetic and Reconstructive Oculoplastic Surgery 9401 Wilshire Blvd. Suite 1105 Beverly Hills, CA.
Christopher I. Zoumalan, M.D., Inc. Aesthetic and Reconstructive Oculoplastic Surgery 9401 Wilshire Blvd. Suite 1105 Beverly Hills, CA. 90212 Date: Patient Registration Information ame Last First Middle
More informationcreating the best life for all children
Patient Information: creating the best life for all children Child s full name: Date of Birth: Age: Sex: M / F Address: City: State: Zip: Is the patient a foster child? Yes No Case Worker Name: Phone:
More information*A COPY OF YOUR CHILD S IMMUNIZATION RECORD MUST BE FORWARED TO THE HEALTH OFFICE PRIOR TO ADMITTANCE*
WASHINGTON ACADEMY STUDENT HEALTH INFORMATION PACKET SCHOOL NURSE: PHONE: 973-239-6555 Ext: 204 FAX: 973-239-6335 *A COPY OF YOUR CHILD S IMMUNIZATION RECORD MUST BE FORWARED TO THE HEALTH OFFICE PRIOR
More informationINFORMED CONSENT FOR TREATMENT
INFORMED CONSENT FOR TREATMENT I (name of client) agree and consent to participate in behavioral healthcare services offered and provided by Methodist Services - Community Counseling Services (CCS). I
More informationPatient Registration Form
Date: Padma Sripada MD, Columbia Internal Medicine 2500 Pond View, Suite 202 Castleton on Hudson, NY 12033 Phone: 518-391-2889 Patient Registration Form First Name Middle Last Name... Sex: M F Date of
More informationManhattan-Staten Island Area Health Education Center
Name: First M.I. Last Ethnicity: Date of Birth: Age: Gender: American Indian or Alaskan Native / / M F Month Date Year Asian (Cambodia, Malaysia, Pakistan, Vietnam) Asian (China, Philippines, Japan, Korea,
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 informationNew Substitute Paraprofessional or Secretary Fingerprint-Based Criminal Background Check Procedures
New Substitute Paraprofessional or Secretary Fingerprint-Based Criminal Background Check Procedures You are required to have a fingerprint-based criminal history check. The Tazewell Regional Office of
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 informationSignature (Patient or Legal Guardian): Date:
X-Ray Patient Information: [ ] Male [ ] Female Patient Name: Date of Birth: / / SS#: Mailing Address: City: State: Zip: Phone # s: (Home) (Work) (Cell) Referring Physician: Phone #: /Fax#: Additional Physician:
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 informationParticipant is a: Student Cabin Leader Adult Chaperone Teacher/School Staff PARTICIPANT INFORMATION Name Male / Female/ Other Date of Birth Age
Registration and Health Form ** REQUIRED FOR ALL PARTICIPANTS** Please complete BOTH sides of this form legibly and in ink. Be sure to SIGN where indicated. Return to the participant s school. Please call
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 informationMESA Summer Academy: Solar System Mission Possible Application Deadline: June 1, 2018 Early Bird Discount Deadline: May 1, 2018
MESA Summer Academy: Solar System Mission Possible Application Deadline: June 1, 2018 Early Bird Discount Deadline: May 1, 2018 Program Description Get a head start on your career in space exploration
More informationAVI Systems, Inc. Employment Application
Employment Application 952-949-3700 9675 West 76th Street, Suite 200 Eden Prairie, MN 55344 www.avisystems.com Applicant Information Date: Last First M.I. Street Address Apt/Unit # City State ZIP Code
More informationDiane Kulas, LSW. Dear Parent/Guardian,
Dear Parent/Guardian, Thank you for your interest in Camp Chimaqua, an overnight bereavement camp, through Hospice & Community Care s Pathways Center for Grief & Loss. The camp will be held on June 9-11,
More informationStaff Training. Understanding Healthix Patient Consent
Staff Training Understanding Healthix Patient Consent Healthix Facilitates Exchange of Data Healthix Policy and Patient Consent Work Responsibilities: Training, Documenting and Preparing for Audit 1. Let
More information12086 Ft. Caroline Road, Suite #401, Jacksonville, FL Phone: (904) Fax: (904) Patient Full Legal Name Date
12086 Ft. Caroline Road, Suite #401, Jacksonville, FL 32225 Phone: (904) 565-1271 Fax: (904) 645-7325 James A. Joyner, IV, MD, Kia M. Mitchell, MD, Thanh Nguyen, MD Dewey Lee, III, PA, Linda Rowan-Vander
More informationPATIENT INFORMATION FORM
PATIENT INFORMATION FORM Name: E-Mail: New Patient? Previous Patient? Previous name if different: Age: Date of Birth: Social Security #: Sex: Female Male Marital Status: S M W D Home Address: City: State:
More informationSummer Day Camp Registration 2018 Pierce County School Based Day Camps YMCA OF PIERCE AND KITSAP COUNTIES
Summer Day Camp Registration 2018 Pierce County School Based Day Camps YMCA OF PIERCE AND KITSAP COUNTIES Completed registration is due the Wednesday prior to first day of camp. Return registration to
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 informationDECLARATION AND CONSENT TO TREATMENT
3160 Steeles Avenue East, Suite 204 Markham, ON L3R 4G9 T. 905.477.0200 F. 905.477.0028 E. info@mnhc.ca W. www.mnhc.ca DECLARATION AND CONSENT TO TREATMENT Patients Name _ Date City Province Postal Code
More informationMRI Patient Screening and History
Griffin Imaging, LLC 220 Rock Street Griffin, GA 30224 (770) 229-4660 Fax:: (770) 229-4632 Specializing In Open MRI, CT & Ultrasound MRI Patient Screening and History Patient Information Sheet PATIENT
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 informationSHORELINE ALLERGY & ASTHMA ASSOCIATES, LLP
DORON J. BER, M.D., FAAAAI DANIEL L. WAGGONER, M.D., MAAAAI MAHESH NETRAVALI, M.D.,MAAAAI 23 CLARA DRIVE. BILLING DEPT: 860-536-8375 314 FLANDERS ROAD. MYSTIC, CT 06355 EAST LYME, CT 06333 860-536-2995
More informationPATIENT NOTICE. If you are already taking any of the above medications, your provider may want to talk to you about alternative treatments.
PATIENT NOTICE Our goal at is to provide quality medical care. Because of our concern for your health and well-being, there are certain types of medications we may not be able to prescribe to you. Examples
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 informationWelcome to University Family Healthcare, PA.
Welcome to University Family Healthcare, PA. We re delighted that you have chosen us as your primary care providers. We work hard to earn your trust and to see that you have the best healthcare possible.
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 informationParent/Guardian Names: Cell Phone: School: Parent/Guardian Signature: Date:
SPIRIT OF AMERICA BOATING SAFETY PROGRAM Offered by Sailing Center Chesapeake & St. Mary s College of Maryland Open to students who have completed 6 th, 7 th, or 8 th grades in 2017. Summer 2017 Student
More informationHealth Care Directive
Health Care Directive Overview Adults with decision-making capacity have the right to make choices about their health care. No treatments may be given to someone who does not want them. The attached Durable
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 informationMonaLisa Touch Patient Questionnaire & Health History
MonaLisa Touch Patient Questionnaire & Health History Name: (Last) (First) (Middle) Date of Birth: Age: Occupation: Home Address: City: State: Zip: Home Phone: Cell Phone: Work: E-Mail Address: May we
More informationPatient Name: Date of Birth: Sex: M F. Patient's SSN: Home Phone: Pediatrician: Home Address: City, State, Zip:
PATIENT INFORMATION Patient Name: Date of Birth: Sex: M F Patient's SSN: Home Phone: Pediatrician: Home Address: City, State, Zip: How was your child referred to our office?: Emergency Room Pediatrician
More information