MyChart - School Based Health Services Consent Form

Cleveland Metropolitan School District (“CMSD”) and Say Yes Cleveland (“SYC”) partner with community agencies to offer additional School-Based Health Services. Completion of this consent form is required for your child to receive these health services from CMSD partner health providers. School nursing and emergency services will be provided whether or not you choose to take part in these added services

This form will time out after 20 minutes, and anything not yet submitted will be lost. Please have the student/patient's insurance and pharmacy information ready before you begin.

**All fields marked with * are required fields**

School District:

PLEASE SELECT A SCHOOL DISTRICT.

Student/Patient Information:

Student First Name

Student Last Name

Student Date of Birth:

Student Sex:

Student Home Address

Student City

Student State

Student Zip Code

Student Home Phone Number

Student School Name

Student Preferred Language

Is this student Hispanic/Latino?

Student Race:

Legal Guardian Information (This will be the primary person contacted concerning the student’s health) :

Guardian’s First Name

Guardian’s Last Name

Guardian’s Date Of Birth:

Guardian’s Employer Name (if available)

Guardian’s Phone Number

Guardian’s Email Address

Guardian Relationship to Student

Guardian Lives with Student?

Student/Patient Insurance Information (If known):

Student has insurance?

Name of Insurance Company:

Subscribers Name

Group Number

Subscriber Number

Emergency Contact Information (Other than legal guardian)

Full Name

Phone Number

Relationship to Student

May we leave a message?

Student Health Information (to be completed by parent/legal guardian)

Please select all that apply (To select multiple items, hold down the CTRL key and then click on each item.)

Other (Please explain):

Primary Care Provider Information

Name of Primary Care Provider/Physician (PCP)

PCP Location

Preferred Retail Pharmacy

Pharmacy Name

Pharmacy Address

Pharmacy Phone Number

Student/Patient Allergies and Immunization History

Does the student/patient have any allergies?

Please select student/patient's allergies:(To select multiple items, hold down the CTRL key and then click on each item.)

Has the student/patient ever had a reaction to any immunization/shot?

If YES, please explain

List immunization/shot that caused reaction:

Services: Additional school-based health services may include the following services unless you tell us not to.

Please select any services you DO NOT want the student/patient to receive (To select multiple items, hold down the CTRL key and then click on each item.)

Please select any services you DO NOT want the student to receive:

Immunizations (shots): The student/patient's school nurse and the MH School Health Program will review the student/patient's record to determine which shots are needed. We will provide additional immunizations unless you tell us not to.

Please select any shots you DO NOT want the student/patient to receive (To select multiple items, hold down the CTRL key and then click on each item.)

Please select any School-Required Immunizations you DO NOT want the student to receive:

Please select any Pediatric/Adolescent Recommended Immunizations you DO NOT want the student to receive:

Please visit https://www.immunize.org/vis to find the Vaccine Information Statement for each vaccine, which will explain risks and benefits of all vaccines.

Consent for Health Services/Treatment and Agreement of Financial Responsibility

PLEASE SELECT A SCHOOL DISTRICT.

Click here to agree to the Consent for Health Services/Treatment and Agreement of Financial Responsibility

Authorization to Release Health Information and Notice of Privacy Practices Acknowledgement

PLEASE SELECT A SCHOOL DISTRICT.

Click here to agree to the Authorization to Release Health Information

PLEASE SELECT A SCHOOL DISTRICT.

Click here to agree to the Notice of Privacy Practices Acknowledgement

Electronic Signature

Full Name

For complete information on enrollment, visit the MetroHealth School Health Program webpage. To sign up for MyChart and securely access your child's personalized health information any time, day or night, visit the MetroHealth MyChart webpage.

Back to the MetroHealth - Cleveland, OH - Login Page

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Migraines
Premature Birth
Sickle Cell
Spine Disorders
Bladder/Urinary Problems
Seizures
Glasses/Contacts
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Mental Health Concerns
Blood Disorder
Diabetes
Pneumonia
Kidney/Renal Disease
Heart Problem
Developmental Problems
Bowel Disorder
Tuberculosis/TB
Tobacco Use
Substance/Drug Abuse
Past or Current Elevated Lead Level Birth
Other

Integrated Health Form

This form will time out after 20 minutes, and anything not yet submitted will be lost. Please have the student/patient's insurance and pharmacy information ready before you begin.

All fields marked with * are required fields

**All fields marked with * are required fields**