Cony Middle and High School SBHC Enrollment an Consent

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Cony Middle and High School SBHC Enrollment an Consent

Please fill out the following information to enroll your student in in the Student Based Health Clinic.

Please Note: A hard copy of the consent form must also be signed and turned into the Health Center for your student to receive health services from our medical affiliates.

Email *

Record my email address with my response

Student Last Name *

Student First Name

Student Middle Initial

Student Date of Birth *

YYYY

Sex Listed on Student's Birth Certificate *

Male

Female

Student Race

Student's Preferred Pronouns

Parent/ Guardian #1 (Name/ Relationship) *

Address *

Phone Number *

Parent/ Guardian #2 (Name/ Relationship)

Address

Phone Number

Preferred Method of Non-Urgent Parent Communication

Phone

Clear selection

Primary Care Provider

Primary Care Provider Phone Number

Preferred Pharmacy

Please list any medical issues or special health concerns related to your student. Please include any past illnesses, injuries, or surgeries.

Current Medical Diagnoses

Please List Current Medications

Please List Medication Allergies

Family Health History

Heart Attack

Allergies

Seizure Disorder

Alcohol or Drug Abuse

Heart Disease

Asthma

Cancer

High Blood Pressure

Sickle Cell Disease

Diabetes

Mental Illness

Please provide any other pertinent information about your student that will assist our medical professionals in assisting your student.

Submit

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This form was created inside of Augusta School Dept.