YES! I would like HealthSource of Ohio to send me the permission form for School-Based healthcare for my child.

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If you are interested in having your child seen by HealthSource of Ohio for medical care, mobile health services, transportation, etc. please complete this form so that the permission packet can be sent to you. Please note: you will always be contacted by your child's school prior to treatment.

Email *

Child's Legal First Name *

Child's Legal Last Name *

What School does your Student Attend?

EX: Goshen Marr/Cook

EX: WC Summerside

Please Provide your Child's Date of Birth: EX: 3/1/20 *

Please Provide your Phone Number *

Please Provide your Mailing Address

address, city, state, zip code

EX: 1111 HSO Rd. Loveland, OH 45140

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