SBHC Consent V1.5 Prod

SCHOOL BASED HEALTH CARE CONSENT FORM

I know the CHC School Based Health Care (SBHC) can give health service for students. One consent form per student must be signed and on file at Community Health Care, Inc (CHC) for the student to receive these services
Patient Name*

First NameMiddle NameLast Name
Patient Birthdate

MonthDayYear
Date
Your name (Parent / Guardian / Head of Household)*

First NameLast Name
School District Name
Name of School your child attends*
I know as a parent, legal guardian or student under Illinois law, I have a right to refuse services. Please select NO if you do not want your child to receive health care services at CHC*

YES, I agree to allow the staff of Community Health Care, Inc through School Based Health Care (SBHC) to treat the needs of my child.NO, I do NOT consent for my child to receive medical care at CHC through School Based Health Care.
I know that I need to update the consent form if it changes. This is valid until I tell CHC to cancel it.
Please check all that I consent for my child to receive as part of School Based Health Care:*

Wellness exams and sports physicalsVaccinesManaging Health Conditions (Asthma, Diabetes, ADHD etc)Sick VisitsMental Health Services
Has your Child / Student been seen by a CHC Medical provider in the last 2 years*

NoYes
Release of Information
I give permission to share protected medical information between CHC and your child's school as indicated above for the services selected above. This shall remain in effect throughout the student's time in school unless you tell CHC you want to change it. The consent does not include releasing any information about treatment for drug and alcohol use, sexually transmitted information, HIV status.I do not permission to Community Health Care and school indicated above for the services selected
By signing this consent, I agree I am the parent / legal guardian of the above listed student and am authorized to give this consent.
Parent / Guardian Signature*

Clear
By signing this form, I agree to allow the staff of Community Health Care, Inc through School Based Health Care (SBHC) to treat the needs of my child.
How are you related to Child*

ParentGuardian
Date*

MonthDayYear
Date
Should be Empty:

SCHOOL BASED HEALTH CARE CONSENT FORM

I know that I need to update the consent form if it changes. This is valid until I tell CHC to cancel it.

Release of Information

By signing this consent, I agree I am the parent / legal guardian of the above listed student and am authorized to give this consent.