Please read the attached Welcome Letter and Notice of Privacy Practices. You may print a copy of this for your records. NOTE: Please complete the following registration. Please DO NOT "X" out at any time -- this will create an incomplete response and we will not be able to register your student.
Parent/Legal Guardian of Student (please type your name -- First & Last)* must provide value
Student's Last Name* must provide value
Student's First Name* must provide value
Student's Middle Initial (optional) Student's Date of Birth* must provide value
Today M-D-Y Student ID #* must provide value
Street Address:* must provide value
City:* must provide value
State:* must provide value
Zip Code:* must provide value
SERVICES PROVIDED BY THE SCHOOL-BASED HEALTH CENTER INCLUDE: In consenting to permit my student to participate in the School-Based Health Center, I acknowledge and agree to the following:
I have had the opportunity to receive and review the Christiana Care Health Services' Notice of Privacy Practices brochure, which is attached. TELEHEALTH I UNDERSTAND that insurance may be billed for covered services and I agree to provide insurance information before services are provided. I UNDERSTAND that the School-Based Health Center shall not charge co-pays or any other out-of-pocket fees for use of its services. I UNDERSTAND this consent may be revoked in writing at any time, except to the extent that action has been taken in reliance on this consent. The revocation must be in writing and sent to the School-Based Health Center associated with my student's care. I AGREE that school staff can accompany my child for medical exam. I AGREE that all information provided on the registration Health History Form and this consent is accurate and complete. I UNDERSTAND that under certain circumstances with my permission and at my request, my student may be seen at a different School-Based Health Center within the School District for certain services. My student and I have read this form carefully, and all my questions have been answered to my satisfaction. I understand that I may call the School-Based Health Center Coordinator if I have any questions before or after I sign this Consent for Services. PARENT/LEGAL GUARDIAN SIGNATURE: I, ______ , give my consent for ______ ______ to receive health services at the School-Based Health Center administered by Christiana Care. (Please click on the green plus sign to the right of the page to add your signature.) * must provide value
( MB)
Parent/Legal Guardian Date/Time Signed:* must provide value
Now M-D-Y H:M I, ______ , assign (please enter name of person to the right) as a decision maker, in my place, for ______ ______ , DOB ______ . enter name of decision maker
Decision Maker's Phone Number: please enter as xxx xxx xxxx with no dashes or parentheses
Student's Name: ______ , ______ ______ Student's Address: ______ , ______ , ______ , ______ Student's DOB: ______ Student's Grade* must provide value
K
1
2
3
4
5
6
7
8
Identified Sex* must provide value
Male
Female
Transgender Male
Transgender Female
Decline to Answer
Race (mark all that apply):* must provide value
Caucasian/White
Black/African American
Asian/Native Hawaiian/Other Pacific Islander
American Indian/Alaskan Native
Undetermined
Other
Please specify "Other" race: Ethnicity * must provide value
Hispanic/Latino
Arabic
Non-Hispanic/Latino/Arabic
Other
Please specify "Other" ethnicity: Primary Care Physician Phone Number: please enter as xxx xxx xxxx with no dashes or parentheses
Primary Care Physician/Family Doctor Name (if you need assistance with finding a doctor, please call the SBHC): EMERGENCY CONTACT INFORMATION
Emergency Contact Name: Emergency Contact Relationship to Student: Emergency Contact Phone #: please enter as xxx xxx xxxx with no dashes or parentheses
PARENTAL/LEGAL GUARDIAN INFORMATION
Are you the student's:* must provide value
Mother
Father
Legal Guardian
Mother's Full Legal Name:* must provide value
Mother's Street Address, City, State, Zip Code:* must provide value
Mother's Date of Birth:* must provide value
Today M-D-Y Best Way to Contact Mother:* must provide value
Home Phone
Cell Phone
Work Phone
Mother's Home Phone Number:* must provide value
please enter as xxx xxx xxxx with no dashes or parentheses
Mother's Cell Phone Number:* must provide value
please enter as xxx xxx xxxx with no dashes or parentheses
Mother's Work Phone Number:* must provide value
please enter as xxx xxx xxxx with no dashes or parentheses
Mother's Email Address:* must provide value
please enter NA if there is no email address
Mother's Employer Name & Address: Father's Full Legal Name:* must provide value
Father's Street Address, City, State, Zip Code:* must provide value
Father's Date of Birth:* must provide value
Today M-D-Y Best Way to Contact Father:* must provide value
Home Phone
Cell Phone
Work Phone
Father's Home Phone Number:* must provide value
please enter as xxx xxx xxxx with no dashes or parentheses
Father's Cell Phone Number:* must provide value
please enter as xxx xxx xxxx with no dashes or parentheses
Father's Work Phone Number:* must provide value
please enter as xxx xxx xxxx with no dashes or parentheses
Father's Email Address:* must provide value
please enter NA if there is no email address
Father's Employer Name & Address: Legal Guardian Name (if not mother or father):* must provide value
Relationship to Student:* must provide value
Legal Guardian's Street Address, City, State, Zip Code:* must provide value
Legal Guardian's Date of Birth:* must provide value
Today M-D-Y Best Way to Contact Guardian:* must provide value
Home Phone
Cell Phone
Work Phone
Guardian's Home Phone Number:* must provide value
please enter as xxx xxx xxxx with no dashes or parentheses
Guardian's Cell Phone Number:* must provide value
please enter as xxx xxx xxxx with no dashes or parentheses
Guardian's Work Phone Number:* must provide value
please enter as xxx xxx xxxx with no dashes or parentheses
Guardian's Email Address:* must provide value
please enter NA if there is no email address
Guardian's Employer Name & Address: INSURANCE INFORMATION (REQUIRED) -- Please complete this information and if you have insurance, please upload a copy FRONT and BACK of your insurance card where prompted below:
What is the primary source of payment for care -- please check one:* must provide value
No Insurance (if you need assistance with obtaining insurance, please contact the SBHC)
Medicaid Provider
Commercial Insurance
Delaware Healthy Children Program
Medicaid Provider Name:* must provide value
Medicaid Number:* must provide value
Medicaid Insurance Card -- please upload a copy of the FRONT of your insurance card ( MB)
Medicaid Insurance Card -- please upload a copy of the BACK of your insurance card ( MB)
Commercial Insurance Name:* must provide value
Commercial Insurance Policy Number:* must provide value
Commercial Insurance Subscriber Name:* must provide value
Commercial Insurance Relationship to Student:* must provide value
Commercial Insurance Subscriber Date of Birth:* must provide value
Today M-D-Y Commercial Insurance Card -- please upload a copy of the FRONT of your insurance card ( MB)
Commercial Insurance Card -- please upload a copy of the BACK of your insurance card ( MB)
What is the secondary insurance information if applicable? Medicaid Provider
Commercial Insurance
Medicaid Provider Name:* must provide value
Medicaid Number:* must provide value
Medicaid Insurance Card -- please upload a copy of the FRONT of your insurance card ( MB)
Medicaid Insurance Card -- please upload a copy of the BACK of your insurance card ( MB)
Commercial Insurance Name:* must provide value
Commercial Insurance Policy Number:* must provide value
Commercial Insurance Subscriber Name:* must provide value
Commercial Insurance Relationship to Student* must provide value
Commercial Insurance Subscriber Date of Birth:* must provide value
Today M-D-Y Commercial Insurance Card -- please upload a copy of the FRONT of your insurance card ( MB)
Commercial Insurance Card -- please upload a copy of the BACK of your insurance card ( MB)
Student's Name: ______ , ______ ______ ______ ______ Does your child have any allergies? (food, medication, latex)* must provide value
Yes
No
If "Yes", please list:* must provide value
please do not use quotes (") or apostrophes (') in your answer as this may cause an error
Please provide the following information about medications your child is taking:
How many medications does your child take? 1
2
3
4
5
More than 5
None
Name of first medication specify one medication at a time
Reason for taking the first medication Start date for the first medication Today M-D-Y Name of second medication specify one medication at a time
Reason for taking the second medication Start date for the second medication Today M-D-Y Name of third medication specify one medication at a time
Reason for taking the third medication Name of fourth medication specify one medication at a time
Start date for the third medication Today M-D-Y Reason for taking the fourth medication Start date for the fourth medication Today M-D-Y Name of fifth medication specify one medication at a time
Reason for taking the fifth medication Start date for the fifth medication Today M-D-Y Please list the names of each medication, reason for taking, and start date for each: please do not use quotes (") or apostrophes (') in your answer as this may cause an error
Please check which of the following your CHILD has ever had:* must provide value
Acne/Skin Problems
ADHD/Learning Disability
Anemia
Anxiety
Arthritis
Asthma
Cancer
Chicken Pox
Cystic Fibrosis
Diabetes
Depression
Fainting Spells
Frequent Colds
Headaches
Head Injury
Heart Disease
Heart Murmur
Hemophilia
Hepatitis
High Blood Pressure
High Cholesterol
Kidney/Bladder Disease
Pregnancy/Childbirth/Miscarriage
Rheumatic Heart Disease
Scoliosis
Seasonal Allergies
Seizures
Sickle Cell
Sleeping Problems
Sports Injury
Stomach/Intestinal Problems
Suicide Attempts
Suicidal Thoughts
Substance Abuse
Thyroid Disease
Tuberculosis
None
If any of the above are checked, please give more detail: please do not use quotes (") or apostrophes (') in your answer as this may cause an error
Has your child ever been hospitalized?* must provide value
Yes
No
If "Yes", please state the reason for hospitalization:* must provide value
please do not use quotes (") or apostrophes (') in your answer as this may cause an error
If "Yes", when and where was your child hospitalized?* must provide value
please do not use quotes (") or apostrophes (') in your answer as this may cause an error
Has your child ever received counseling for emotional health?* must provide value
Yes
No
If "Yes", what was the reason for counseling:* must provide value
please do not use quotes (") or apostrophes (') in your answer as this may cause an error
If "Yes", when and where did your child receive counseling?* must provide value
please do not use quotes (") or apostrophes (') in your answer as this may cause an error
Please check any of the following illnesses that your FAMILY MEMBERS (parent, brother, sister, grandparent, aunt, uncle, etc.) have ever had: ADHD/Learning Disability
Alcoholism/Drug Abuse
Anemia
Arthritis
Asthma
Birth Defects
Cancer
Cystic Fibrosis
Deafness
Diabetes
Headaches
Heart Disease
Hemophilia
Hepatitis
High Blood Pressure
High Cholesterol
Kidney/Bladder Disease
Mental Illness
Obesity
Seizures
Sickle Cell
Stroke
Thyroid Disease
Tuberculosis
Unexplained Death
Other
If "ADHD/Learning Disability", which FAMILY MEMBER: If "Alcoholism/Drug Abuse", which FAMILY MEMBER: If "Anemia", which FAMILY MEMBER: If "Arthritis", which FAMILY MEMBER: If "Asthma", which FAMILY MEMBER: If "Birth Defect", which FAMILY MEMBER: If "Cancer", which FAMILY MEMBER: If "Cystic Fibrosis", which FAMILY MEMBER: If "Deafness", which FAMILY MEMBER: If "Diabetes", which FAMILY MEMBER: If "Headaches", which FAMILY MEMBER: If "Heart Disease", which FAMILY MEMBER: If "Hemophilia", which FAMILY MEMBER: If "Hepatitis", which FAMILY MEMBER: If "High Blood Pressure", which FAMILY MEMBER: If "High Cholesterol", which FAMILY MEMBER: If "Kidney/Bladder Disease", which FAMILY MEMBER: If "Mental Illness", which FAMILY MEMBER: If "Obesity", which FAMILY MEMBER: If "Seizures", which FAMILY MEMBER: If "Sickle Cell", which FAMILY MEMBER: If "Stroke", which FAMILY MEMBER: If "Thyroid Disease", which FAMILY MEMBER: If "Tuberculosis", which FAMILY MEMBER: If "Unexplained Death", which FAMILY MEMBER: If "Other", please specify type of illness and FAMILY MEMBER:
Working...