SBHC Consent Form Port Chester
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SBHC Consent Form Port Chester

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Port Chester-Rye UFSD School Based Health Center Consent Form

All fields marked with * are required.
*Office Location:
*Student Name:
*Date of Birth:
*Address: (Street, Apt. #, City)
*Zip Code:
*State:
I give consent for my son/daughter to receive services at the Port Chester UFSD School Based Health Center. I authorize
a provider or designated health professional to provide health services as follows.

- Routine physical exams
-Diagnosis and treatment of acute and chronic illness
-Treatment of minor injuries
-Vision and hearing screenings
-Immunizations
-Health education, counseling, and wellness promotion
-Nutrition education and weight management
-Preventative dental care (including screenings and treatment)
-Sports physicals
-Prescription medications
-Age appropriate reproductive health services, e.g., abstinence/family planning counseling, education, exams,
pregnancy and STD testing, and referrals
-Mental Health/ Behavioral Health
-Referral for health care services which cannot be provided at the School Based Health Center.
I give permission for necessary medical tests, evaluations, and management of my child's medical care.
I consent to the exchange of health history between the school nurse, child's doctor, counselor, social worker at FSW or
Guidance Center and any other medical professional that may be necessary for the health of my child. The student's
health center record is electronic and will be maintained as a confidential medical record; it is not a school record. I also
understand confidentiality will be observed between school staff and the student's using the Center.

I further authorize Open Door Family Medical Centers to release information regarding treatment to third party payers or
other for purposes of billing and for any reason that may be required to comply with statutes or regulations in accordance
with accepted medical practices.

I have read the above information and have had the opportunity to have any of my questions answered. I understand
that this consent form will remain in effect as long as my child is enrolled in the Port Chester-Rye UFSD, unless I notify
the Health Center in writing. I understand that I may revoke my consent at any time.

I also understand that this form will automatically expire when the student named above is no longer enrolled in an
elementary school served by SBHC program.
*Signature of Parent or Legal Guardian:

Please sign in the box below using your mouse, touch screen, or touchpad.

Clear    Use Most Recent Signature

I accept that this is the legal representation of my signature.

*Date:
Contact Information
Home Phone:
Day Phone:
*Cell Phone:
*Please select one of the following:
*School:
*Grade:
*Does your child have health insurance?