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:
• Comprehensive health assessments (for students without a primary care physician)
• Immunizations
• Diagnosis and treatment of minor, acute and chronic medical conditions
• Nutrition counseling and education
• Referrals to and follow-up for specialty care, oral and vision health services
• Mental health, crisis intervention, counseling and treatment
• Referral to mental health and substance abuse services including emergency psychiatric care, community and support programs
THE SCHOOL-BASED HEALTH CENTER DOES NOT PROVIDE THE FOLLOWING SERVICES:
• Treatment or testing of complex medical or psychiatric conditions
• Ongoing primary treatment of chronic medical conditions
• Complex lab tests
• Hospitalization
• X-rays
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 "telehealth" is the mode of delivering health care services using digital communication technology to help evaluate, diagnose, consult, educate, monitor, and manage care and treatment without being in the same physical location as my provider.
I understand that a telehealth visit is not the same as an in-person visit because I will not be in the same room with my provider. I understand that I will not be treated through telehealth unless my condition supports the use of this technology as my provider will not be able to perform some aspects of a full physical examination.
I understand that digital communication technology may include, but not be limited to real time two-way audio, video, or other telecommunications or electronic communications, including remote patient monitoring, secure video conferencing, and/or secure texting with my care team.
I understand that there are benefits to utilizing telehealth services, which include, but are not limited to, convenient medical evaluation and management. I also understand that there are risks involved in receiving treatment through telehealth, which include, but are not limited to interruption in the audio/video connection that may result in the visit being postponed until a later time and/or performed through an alternate method, and, in rare cases, unauthorized access to my confidential information. In the event of a technical failure, I understand that I should immediately contact my provider's office, or, if it is an emergency, dial 911.
I understand that laws protecting the confidentiality of my medical information also apply to telehealth and that ChristianaCare uses security protocols to help protect my privacy and ensure my confidential communications are sent only to the intended care team member(s).
I understand that ChristianaCare will not record the video or audio of my telehealth visit without my consent at the time of the recording.
I consent to have ChristianaCare obtain health information from me and provide health care services to me through telehealth communications when and where my provider or qualified member of my care team determines it is appropriate and necessary.
I understand that I may refuse or stop participation in telehealth services and request alternate services, such as an in-person visit, at any time.
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 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. I AGREE that all information provided on the registration Health History Form and this consent is accurate and complete. 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 ______ ______ , DOB ______ , who resides at ______ , ______ , ______ , ______ , to receive health services at the Christiana Middle School-Based Health Center (SBHC) administered by Christiana Care.
And by my signature, I certify that I am the parent or legal guardian of the student named above and have read the consent statements about services offered at my student's School-Based Health Center and voluntarily agree to have my student participate. I acknowledge that I have been given no guarantee or assurance as to the results that may be obtained from the services/treatment. (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 Student's Name: ______ , ______ ______ Student's Address:
______ , ______ , ______ , ______ Student's DOB: ______ Student's Grade* must provide value
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/Family Doctor Name (if you need assistance with finding a doctor, please call the SBHC):
Primary Care Physician Phone Number:
please enter as xxx xxx xxxx with no dashes or parentheses
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:
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:
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:
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: ______ , ______ ______
Student's DOB: ______
Student's Grade: ______ 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
Reason for taking the first medication
Start date for the first medication
Today M-D-Y Name of second medication
Reason for taking the second medication
Start date for the second medication
Today M-D-Y Name of third medication
Reason for taking the third medication
Start date for the third medication
Today M-D-Y Name of fourth medication
Reason for taking the fourth medication
Start date for the fourth medication
Today M-D-Y Name of fifth medication
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
Primary Care Provider Name: ______ 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: