Medical/Dental Home & Insurance Information

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Child's Name (last, first) *

Insurance (please check one) *

Yes, have Medicaid

Applying for Medicaid

Private Insurance

None

Other:

Child's Physician/Health Department *

Hospital *

Child's Dentist *

Dental Insurance (Choose One) *

Yes

Required

Individualized Health Plan

Please check all health conditions that apply for your child *

No known health problems at this time

Asthma

Cancer

Diabetic

Epilepsy

Febrile Seizures

Heart Condition

Over/Under Weight

Skin Condition

Other:

Required

Allergies (i.e. environmental, food, medications, etc.) If none please indicate none *

EpiPen *

Permission to post information regarding your child's allergies in classroom? *

Referral Source/Treatment Plan

How was the Health Condition identified? *

Parent/Guardian

Healthcare Provider

Health Form

N/A

Other:

Required

Status of Health Condition *

No treatment required

Aware of condition

Child currently under M.D. care

N/A

Required

If child is currently under M.D care please list M.D.'s name and phone number. If child is not currently under M.D. care please indicate with N/A. *

Please list current Medications/Treatments. If no current medications/treatments please indicate with N/A. *

Please list known Side Effects for child. If no know side effects please indicate with none or N/A. *

Please list Limitations. If no limitations indicate with N/A. *

Please provide Emergency Instructions for child. If emergency instructions are not needed indicate with N/A. *

Health Services Authorizations

THE FOLLOWING HEALTH SERVICES ARE REQUIRED. School staff, health department, or other medical professionals could provide the services listed below. I acknowledge these are required and give my consent for services. Services include: physical exam, sickle cell, vision screening/eye exam, hearing screening, up-to-date immunizations, dental exam, behavioral health screening review/observation/consultation, speech/developmental screening, height/weight, nutrition assessment, blood pressure, TB risk assessment, blood lead level and hemoglobin/hematocrit.

Emergency Information & Authorization

I understand that in a medical/dental emergency, an ambulance may be called or Head Start personnel may transport my child. I authorize my child to receive emergency medical/dental treatment from the nearest appropriate facility.

By choosing Yes you agree that the above information provided is correct, to the Health Services Authorization and Emergency Information and Authorization. Also that by choosing yes this is the equivalent of a signature. *

Yes

Date Form Completed *

YYYY

Copy of information may be sent to teacher, food service, school nurse, bus driver, etc. *This form is required if treatment not covered by medication authorization, documented on physical, or IEP/ARC. Signatures on this form give permission for as long as the child is enrolled in the program, unless we are notified otherwise or health changes occur.

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