ETSU College of Nursing School-Based Health Centers
Consent for Health Care
Please read carefully and sign this consent authorization in order for your child to receive health care at the
ETSU College of Nursing School-Based Health Centers.
I hereby voluntarily give my consent for (student’s name) _____________________________ to receive health
services offered by the school-based health center staff and health care providers that include nurse
practitioners, physicians, registered nurses, and licensed practical nurses employed by or working for the health
center. I further authorize the school-based health center staff to provide medical care for my child in the
absence of the parent/legal guardian. This care may include first aid, assessment and treatment of acute and
chronic illnesses, tests, procedures, and care designed for health promotion and disease prevention.
In the event that my child requires urgent or emergency medical care and I cannot be reached, I request my
child be treated according to acceptable medical practice, and that I will be contacted as soon as possible. When
urgent or emergency treatment is determined to be necessary off site, and I am unavailable or unable to arrange
transportation, then the school clinic staff will call 911 and arrange for emergency transportation for my child.
This may also be in coordination with the school system or other agencies.
The health center has permission to share information to coordinate my child’s care with the school nurse and
with private providers. I understand that my child’s records will be kept confidential and not be released to
anyone without my consent, except as authorized above or as otherwise provided by law and the federal HIPAA
Guidelines for Confidentiality.
This consent shall remain valid and in effect until revoked by me in writing or separation of my child from the
Washington County school system, whichever shall occur first.
By signing here, I indicate that I am fully informed as to the contents of this document, and understand the full
importance of this consent.
________________________________________
________________________
Signature of Parent or legal Guardian
Date
_________________________/________________________
Phone (Home/Cell)
____________________________
Phone (Work)
Approved by the ETSU Legal Affairs 7/30/08
Student Registration
All information on this form is confidential
Student Name: ______________________________________________ Date of Birth ______________ Age _____ Grade _____ Sex ______ Race ______
Phone Number: (H) ____________________ (W) ___________________ (Cell) ____________________ Social Security number: _______________________
Emergency Contact Name:______________________________________ Phone: ___________________ Relation to student:___________________________
Address: _________________________________________________________________________________________________________________________
What is your child’s usual source of health care: Office/Clinic ______ Emergency Room ______ None ______ Date of last visit _____________________
Name of Primary Care Provider: ___________________________ Address: ___________________________________________ Phone: __________________
Insurance Company: ________________________________________________ Policy Number ______________________ Group Number _______________
Address for Claims: _________________________________________________________________________________________________________________
Subscriber Name: _________________________________________ Date of Birth: _________________ Social Security Number: ________________________
Address: ___________________________________________________ Phone:____________________ Relationship to patient: ____ _____________________
Student Health History
Medication/Food Allergies: (1) _______________________ (2) _______________________ (3) _______________________ (4) _________________________
List any medications your child takes on a regular basis:
Medication
_____________________________________
_____________________________________
_____________________________________
_____________________________________
Reason for taking
____________________________________________
____________________________________________
____________________________________________
____________________________________________
Dose
___________________________
___________________________
___________________________
___________________________
Hospitalization/Surgeries:
Date
__________
__________
__________
Age
__________
__________
__________
Problem
_________________________
_________________________
_________________________
Treatment
__________________________________________
__________________________________________
__________________________________________
Child’s History: Please check if your child has/had any of the following problems:
___Allergies
___Anemia
___Asthma
___Add
___ADHD
___Bladder/Kidney
___Bedwetting
___Cancer
___Chicken Pox
___Depression
___Eating Disorder
___Emotional Disorder
___Genetic Disorder
___Headaches
___Heart Disease
___Hearing
___Hepatitis
___Respiratory Disorder
___Rheumatoid
___Seizures
___Sickle Cell Disease
___Smoker
___Stomach Problems
___Thyroid Disease
___Visual Problems
___Other
Family History: Are there any relatives, living or deceased with any of the following problems?
___Alcoholism/Drug abuse
___Allergies/Asthma
___Anemia
___Arthritis
___Birth Defects
___Cancer
___Diabetes
___Endocrine/Gland Disease
___Family Violence
___Headaches
___Liver Disease/Hepatitis
___Heart Attack/Stroke
___Kidney Disease
___Lung Disease/TB
___Mental Illness
___Mental Retardation
___Obesity
___Seizures/Epilepsy
___Sickle Cell Disease
___Smoking
___Stomach Problems
___Thyroid Disease
___Vision/Hearing Problems
___Other
In the past year, have there been any changes in your family such as:
___Marriage
___Separation
___Divorce
___Serious illness
___Births
___Deaths
___Change in school
___Loss of job
___Move to new home
___Move to new school
___Other
Please describe below any special concerns or additional information you have about your child’s health that can help us give the best care to her/him.
Please be sure to call us if there is a change in this information or if you are worried about your child’s health