Consent Form & Demographics for 2020-2021
Please read, fill out and type your Full Name and cell number. By typing your name into the Parent/Guardian field, you are typing your digital signature and are agreeing to allow the School-Based Clinic to provide the following services for your child. All services are provided by licensed professionals.
Acute Care for Minor Illness and Injury
Behavioral Health Services
Behavioral Risk Assessment
Laboratory and Diagnostic Testing (STD testing when applicable)
Comprehensive History and Physical Exams
Health Education and Prevention
Referral and Follow Up for Emergencies
Primary and Preventive Health Care
Referral to Specialty Care
Immunizations (with additional consent)
A follow-up verification call will be made to the provided contact number for us to validate this consent.
Do you agree to the above notice?
I agree and wish to continue filling out the consent.
I do NOT agree and wish to opt out.
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This form was created inside of Trinity Community Health Center.