Step 1 of 4 25% Student InformationName* First Middle Initial Last Date of Birth* MM slash DD slash YYYY Age* Social Security Number* Grade* School*Select SchoolAvondale High SchoolFarmington High SchoolFerndale High SchoolPontiac High SchoolPontiac Middle SchoolWhitman Elementary SchoolWaterford Durant High SchoolWaterford Mott High SchoolWaterford Mason Middle SchoolParent/Legal Guardian InformationAddress Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Name* First Last Date of Birth* MM slash DD slash YYYY Social Security Number* Phone*Preferred Language* Emergency Contact Information(Complete only if contact is not the same as parent/guardian)Name First Last PhoneRelationship to student Services Provided at the School-Based Health CenterParental Consent is required for the following services provided to patients under the age of 18: Health maintenance Exams Physical exams for school, sports, camp and work Treatment for acute and chronic illnesses and injuries Vision/hearing screenings and follow up Oral/dental screenings and follow up Immunizations Basic laboratory services and tests Medication administration Individual, group, family and community education Referrals for specialty services Current Michigan law allows for confidential services to minors aged 12 and up. Parental consent is not required for: Pregnancy testing Sexually Transmitted Infection screenings, treatment/counseling HIV counseling, testing, and referrals Physical/sexual abuse counseling and referrals Substance abuse education, counseling, and referrals Crisis intervention and emergency care Mental Health and psycho-social assessment, counseling, and referral (must be 14+ to consent) Services Not Provided at the School-Based Health CenterPer Michigan Law: Birth control pills and contraceptive devices are not dispensed or prescribed on school premises Abortion counseling, referrals, or services are not provided Parent/Legal Guardian ConsentI consent to the following: The above-named student may receive all services listed above at the School-Based Health Center Exchange of healthcare information between the School-Based Health Center and the student’s primary care physician and other established healthcare providers for continuity and coordination of care according to state & federal laws Release of information regarding treatment to third party payers or others for the purpose of receiving payment for services In certain situations, the delivery of care may include telemedicine: My health care provider has explained how the video conferencing technology will be used to affect a consultation. I understand that this consultation will not be the same as a direct patient/health care provider visit due to the fact that I will not be in the same room as my health care provider I understand there are potential risks to this technology, including interruptions, unauthorized access and technical difficulties. I understand that my health care provider or I can discontinue the telemedicine consult/visit if it is felt that the videoconferencing connections are not adequate for the situation. I understand others may also be present during the consultation other than my health care provider and consulting health care provider in order to operate the video equipment. I further understand that I will be informed of their presence in the consultation and thus will have the right to request the following: (1) omit specific details of my medical history/physical examination that are personally sensitive to me; (2) ask non-medical personnel to leave the telemedicine examination room; and/or (3) terminate the consultation at any timeName* First Last Date* MM slash DD slash YYYY Consent By signing this consent form, I confirm thatI am the custodial parent and/or legal guardian of the above-named student and the insurance information is current and correct. I understand that I may withdraw my consent or refuse services upon written notice to the health center at any time.COVID Consent* By signing this consent form, I confirm thatThe above-named student may receive COVID-19 evaluation, testing and treatment by the School-Based Health Center. All students who have received COVID-19 testing through the School-Based Health Center will have results communicated to the parent/guardian as well as school administration prior to returning to school. I understand that positive test results require reporting to the Oakland County Health Department.Immunizations Consent* By signing this consent form, I confirm thatI understand my child’s immunization records from the Michigan Childhood Immunization Registry (MCIR) will be reviewed. If it is determined that my child needs a shot, I give my permission for it to be given at the School-Based Health Center, and I give permission that the administration of the vaccine be recorded in the MCIR. I understand that I will be able to review a written description of the vaccine and/or talk with a vaccine administrator prior to the vaccine being given. Primary Insurance InformationInsurance Company* Policy ID* Group/Plan #* Name of Policy Holder* First Last Relationship to Student* Secondary Insurance InformationInsurance Company Policy ID Group/Plan # Name of Policy Holder First Last Relationship to Student Patient Health HistoryGender at Birth* Male Female Current Gender* Male Female Transgender Male (Female to male) Transgender Female (Female to male) Choose not to disclose Other Sexual Orientation* Straight/Heterosexual Lesbian or Gay Bisexual Something else Don’t Know Choose not to disclose Race* American Indian or Alaska Native Asian or Pacific Islander Black or African American White or Caucasian More than one race Other Ethnicity* Arab Hispanic/Latino Not Hispanic/Latino More than one ethnicity Preferred Language*Select LanguageEnglishSpanishArabicLiving Situation* Not Homeless (Family owns or rents a home/apartment) Homeless Are you worried about losing your housing?* Yes No Student's Primary Care Doctor* Phone*Student's Dentist* Phone*Date of Last Physical Month Day Year MedicationsClick the + to add additional medicationsMedication NameDoseReason Allergies Medication (list below) Seasonal (hay fever, dust, pollen) Bee Stings Food (list below) None List Medications List Food Allergies Please check if your child has any of the following: Anemia Asthma Attention Deficit Disorder (ADD) Blood disease Cancer Dental Problems (add details below) Diabetes Emotional Impairment or Mental Illness Fainting Headaches/Migraines Head Injury Heard Murmur Heart Problems (add details below) HIV/AIDS Hypertension (High blood pressure) Jaundice Kidney or Bladder/Urine problem Liver Disease Menstrual Problems Pregnant (add date below) Rheumatic Fever Seizures (with or without epilepsy) Sickle Cell Trait Sickle Cell Disease Sinus Problems Skin Problems Stomach Problems Venereal Disease Other (add details below) Due Date MM slash DD slash YYYY Details: Family Medical HistoryPlease check if any of your child’s relatives have had any of the following illnesses and note which relative had them below Asthma Anxiety, depression, or other mental illness Cancer Death under age 50 Diabetes Heart Problems Hypertension High Cholesterol Kidney Problems Seizures Sickle Cell Anemia Stroke Who: