Patient Information

First name

Last name

Age in years

Date of Birth

Month

Day

Year

Gender at birth

Male

Female

Grade entering

Which physical are we providing your child?

Sport trying out for / playing (if applicable)

Front of Insurance Card

Back of Insurance Card

Secondary Insurance Card

Preferred Parent/Guardian Phone Number

Preferred Parent/Guardian Email

Preferred pharmacy

Preferred pharmacy address

Country/Region

Address

City

Zip / Postal code

Tuberculosis Risk & Infection Screening

Recent immigrant (< 5 years), frequent visitor to TB endemic areas

No

Yes

Close contact to active TB case

No

Yes

Frequent contact with adults at high-risk for disease, HIV+, homeless, incarcerated, illicit drug user

No

Yes

HIV+ or have other medical conditions that increase the risk to progress from infection to disease, e.g., chronic renal failure, diabetes, hematologic or any other malignancy, weight loss > 10% of ideal body weight, on immunosuppressive medications

No

Yes

Does the child exhibit signs/symptoms of tuberculosis (e.g. cough for three weeks or longer, weight loss, loss of appetite)?

No

Yes

HIPAA Consent

The Health Insurance Portability and Accountability Act (HIPAA) provides safeguards to protect your privacy. There are rules and restrictions on who may see or be notified of your Protected Health Information (PHI). These restrictions do not include the normal interchange of information necessary to provide you with office services. HIPAA provides certain rights and protections to you as the patient. We balance these needs with our goal of providing you with quality professional service and care. Additional information is available from the U.S. Department of Health and Human Services. www.hhs.gov

Consents

I consent to the questioning, history taking, and any medical care including conducting physical exam, practice of performing diagnostics, diagnosing, and treating as determined by the provider of Mobile Pediatric Quick Care to be necessary for the welfare of my child while said child is under the care of Mobile Pediatric Quick Care.

I consent Mobile Pediatric Quick Care to access the patient's full medication history.

I attest that I am the Parent or Legal Guardian of this patient and have the legal right to sign for the patient.

I declare that the info I’ve provided is accurate and complete. I understand that this information will be used by the provider to help determine appropriate and healthful treatment. If there is any change in medical status, I will notify the provider.

Signer's name typed

Signature (sign with finger of mouse)

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