South Portland Middle School- School Based Health Center And Dental Clinic

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This form should be filled out prior to the enrollment form. Please fill out this google form to indicate which services you will be enrolling your child in and we will send student home with form(s). Note: If your child already has a primary care provider, they can still be enrolled in medical services for emergency/acute medical needs during school hours.

Student name and grade:

If your child is an incoming 5th grader for the 24-25 school year, what elementary school do they attend?

Parent name:

Would you like us to contact you with more information regarding our services?

Yes

Clear selection

Phone number or email:

Medical enrollment:

Medical services include primary care, vaccinations, acute care and behavioral/social services.

Yes

Clear selection

Dental enrollment:

Dental services at SPMS include cleanings with our dental hygienists. For appointments with our dentist, we refer to our dental clinic at Portland High.

Yes

Clear selection

If needed, are you interested in your child receiving vaccines at our clinic?

Yes

Clear selection

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