Tug River/ Mt. View Health Center
Enrollment Form
Parents - Please complete and sign this enrollment form to give consent for your
child to use the Medical Services provided at Tug River/ Mt. View Health Center.
Student name_____________________________________ Date of
birth__________________
Address___________________________________________________________
___________ Parent/Guardian Home phone_____________Cell Phone:
__________ Work phone_________
What Grade is the Child in This Year: _______
Parent(s) or legal guardian(s)
______________________________________________________
Address (if different than above)
__________________________________________________
Daytime phone if different than above:________________________
Primary Doctor or Health Care
Provider_____________________________________________
Address_______________________________________________
Phone__________________
Check here if student does not have a primary doctor or health care provider
______
Is your child eligible for the free or reduced lunch program? ____Yes _____No
Student Health Information
Please list below any known medical issues or special health concerns that will help
us with your child’s health care management.
Significant past illnesses, injury or hospitalizations
____________________________________
_________________________________________________________________
_____________
Current health problems
__________________________________________________________
Current medications
_____________________________________________________________
Allergies to Medications: ___________________________Allergies to foods:
_______________
Is your child going to need any immunizations this year? _____ yes _____ no
_____ don’t know
****IF You Do Not Know if your child needs immunizations, please return a copy of
their shot record and we will assess for the need for any needed vaccines, we will
not vaccinate without your separate consent*******
Check here if student had his/her last physical exam over one year ago ______
Family Health History – Please check off where there is a family history of any of
the following health conditions:
________ Heart attack ________ Diabetes________ Heart disease ________
Cancer
________ High blood pressure ________ Seizure disorder________ High
cholesterol
________ Sickle cell disease________ Allergies ________ Tuberculosis
________ Asthma ________ Alcohol or drug abuse________ Immune system
disorder ________ Mental illness
When did you child last visit a dentist?
_________________________________________
Health Insurance Information (please attaches copy of Medical card or complete
the following)
We ask that you provide the information requested below so that Tug River/ Mt.
View health Center can bill your student’s Medicaid and/or Insurance for School
Health Center services provided. PARENTS WILL NO BE BILLED FOR ANY
STUDENT SERVICES.
NO STUDENT WILL BE DENIED HEALTH CENTER SERVICES BASED ON
INCOME, INSURANCE OR MEDICAID STATUS.
Medicaid coverage? _____ yes _____ no If yes, Medicaid number
_______________________
Private insurance coverage? _____ yes _____ no If yes, company name
___________________
Check here if student has no health insurance ______
Consent For Services/ Treatment
_________________________has my permission to use the services provided at
Tug River/ Mt. Student Name View Health Center.
I give consent for Tug River/ Mt. View to evaluate and treat my child. This may
include giving oral over the counter medications, injectable medications such as
antibiotics or steroids, performing venipuncture to obtain laboratory specimens,
and giving nebulized medications. I give the McDowell County School Board
consent to disclose to Tug River/Mt View Health Center my child’s immunization
records if there should be a need for that information. I understand that the
Medical Provider will inform the parents of important symptoms and discuss
treatment recommendations. I also consent for Tug River/Mt View to use and
disclose health/medical information regarding my child for purposes of treating my
child, billing Insurance and health care operations and authorize payment for
services rendered to Tug River/ Mt. View Health Center. I hereby acknowledge
that I have received a copy of the “Notice of Privacy Practices” for Tug River Health
Association and understand that I may contact Tug River/ Mt. View Health Center if
I have questions about the content of the notice. I understand that this consent
remains in effect while my child is enrolled at Mount View Middle/High School and
that I may revoke my consent at any time by notifying Tug River/ Mt. View Health
Center at 436-4798.
_________________________________________________________________
____________
Parent/guardian signature Date
Relationship to child:
____________________________________________________________
Consent to Share Health Information
I authorize the sharing of health information with the following health and social
service professionals that work together with the Student Health Center staff when
it is deemed medically appropriate to do so. Please check off all of the
professionals with whom information can be shared:
_____ Primary doctor or health care provider
_____ Dentist
_____ Medical specialist
_____ School nurse
_____ School social worker or guidance counselor
Parent/guardian signature ________________________________________
Date________
Revised 1/19/2009