Alaska School Telemedicine Registration
Securely register your child for participation in the Alaska school telemedicine program by completing this form. Children at school will be able to see a board-certified Pediatric Provider via coordination between the school nurse or health administrator and the parent(s) or guardian(s) virtually. This program is designed to help provide immediate and reliable access to high quality pediatric care in Alaska for children while at school. 
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Email *
Date *
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Student Last Name *
Student First Name *
Date of Birth *
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Parent/Guardian Full Name *
Parent/Guarantor/Guardian Birthday *
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Parent Phone Number *
Address  *
City *
Zip Code *
Patient Birth Sex *
School District *
School Child Currently Attends *
Primary Insurance Type *
Primary Insurance ID Number
Secondary Insurance (If applicable)
Secondary Insurance ID Number
Preferred Pharmacy  *
Primary Care Provider
Consent *
Required
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