MyChart - School Based Health Services Consent 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**

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 Employer Phone (if available):

Guardian’s Phone Number:

Guardian's Email Address:

Guardian's Relationship to Student:

Guardian lives with Student?

Student/Patient Insurance Information (if known):

Student has insurance?

Name of Insurance Company:

Subscriber's 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

This field is required.

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

these fields are required.

Click here to agree to the Authorization to Release Health Information

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.

Asthma
Cancer/Leukemia
Eczema
Migraines
Premature Birth
Sickle Cell
Spine Disorders
Bladder/Urinary Problems
Seizures
Glasses/Contacts
Hearing Aids
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
Other

School Health Consent 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**