SBHC Patient Intake Applica...

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Back to School Physical Enrollment

Attestations

I give my child/self permission to obtain MEDICAL SERVICES while enrolled in a school serviced by CHC or until I revoke permission. *

I certify that the health information provided is accurate to the best of my knowledge and understand that incorrect information health can be dangerous to the student/patient. I will notify CHC of any changes to medical information. *

Click here to review the CHC Patient Rights and Responsibilities Document

Click her to review and agree to the CHC Patient Rights and Responsibilities Document https://www.chc1.com/patient-rights-and-responsibilities/ *

I authorize the release of any medical, dental or behavioral health information necessary to process my claim. I also authorize payment of health benefits to
Community Health Center, Inc. for services provided. *

Click here to review the CHC Notices of Privacy Practices

Click her to review and agree to the CHC Patient Rights and Responsibilities Document https://www.chc1.com/patient-rights-and-responsibilities/uses and disclosures detailed in the Notice of Privacy Practices, I agree to permit CHC to send text messages to my child (only for scheduling purposes) or to me if a cell phone number(s) is listed below *

AUTHORIZATION FOR EXCHANGE OF HEALTH & EDUCATION INFORMATION: *

Note: I hereby authorize CHC to exchange health and education records with my child s school district for the purpose of providing care and treatment to my child, if applicable, and/or to
exchange physical exam and immunization information required by law. I recognize that health records if received by the school district, may not be protected by the HIPAA Privacy Rule,
but will become education records protected by Family Education Rights & Privacy Act.

Patient Details

Is the child an existing CHC patient? *

Student's First Name *

Student's Last Name *

Student's Middle Name

Sex *

Social Security Number

Student's School *

Student's Grade *

Month of Birth *

Date of Birth *

Year of Birth *

DOB

Student's Primary Language *

Race/Ethnicity *

Ethnicity *

Street 1 *

Street 2

City *

State *

Zip Code *

What type of phone number is your primary phone number?

Student Cell Phone

Student Cell Confirm

Please enter your email address

Student Email

Student Email Confirm

Current Provider Details

PCP Name

PCP Phone

Dentist Name

Dentist Phone

ext.

Insurance Information

Do you have insurance? (i.e. Medicaid, Medicare, Anthem, Cigna) *

To confirm, you do not receive Medicaid or Medicare benefits:

Please indicate the type of insurance/benefit you receive:

Policy Holder First Name

Policy Holder Last Name

Policy Holder Month of Birth

Policy Holder Date of Birth

Policy Holder Year of Birth

Policy Holder DOB

Insurance Provider

Insurance ID

Group Number

Insurance Phone Number

ext.

Please take a photo of the front of your medical insurance card

Please take a photo of the back of your medical insurance card

Secondary Insurance Check

Secondary Insurance Type

Secondary Insurance No

Secondary Group No

Secondary Policy Holder First

Secondary Policy Holder Last

Secondary Policy Holder Birth Date

Secondary Policy Holder Birth Month

Secondary Policy Holder Birth Year

Secondary Policy Holder DOB

Secondary Front

Secondary Back

Dental Insurance

Dental Insurance Provider

Dental Insurance Number

Dental Insurance Group

Dental Insurance Phone Number

Please take a photo of the front of your dental insurance card

Please take a photo of the back of your dental insurance card

Parent Information

Is the student at least 18 years old? *

Parent First Name *

Parent Last Name *

Relationship to Patient *

Same Address as Child?

I agree that messages can be left for me on: *

Parent Street 1 *

Parent Street 2

Parent City *

Parent State *

Parent Zip *

Parent Month of Birth *

Parent Date of Birth *

Parent Year of Birth *

Parent DOB

What Phone type is Parent Primary Phone? *

Valid Cell Phone

Please enter a valid mobile phone number below

Parent Cell

Parent Cell Confirm

Please enter your email address

Valid Email

Parent Email

Parent Email Confirm

Emergency Contact Details

Check to copy from Parent

Emergency Contact First Name *

Emergency Contact Last Name *

Emergency Contact Relationship *

What Phone type is Emergency contact primary Phone? *

Valid Emergency Contact Phone

Please enter a valid mobile phone number below

Best Contact Phone Number *

Emergency Contact Phone Confirm *

Consent for Treatment

By checking this box and signing my name below, I understand and acknowledge that
I have read and understand this consent and I have received CHC s Notice of Privacy Practices currently in effect. *

Signature Date *

Type the parent's name to sign *

Medical History

Does the patient have any medical conditions? *

Please Explain:

Does the patient take any medications? (including inhalers?) *

Please Explain:

Has the patient had any serious injuries? *

Please Explain:

Does the patient have a birth or heart defect or a history of a heart problem or surgery? *

Please Explain:

Has the patient ever been hospitalized overnight? *

Please Explain:

Has the patient had any surgeries in the past? *

Please Explain:

Has the patient had any shunts placed or has an indwelling catheter? *

Please Explain:

Is/was the patient a teen parent? *

Is the patient pregnant or possibly pregnant? *

Pregnant Due Date

Is the patient currently nursing? *

Is premedication with antibiotics needed prior to dental procedures? *

Please Explain:

Does the patient smoke or chew tobacco? *

Medical Issues

Anemia/blood disorders *

Asthma *

Autism *

Bladder or Kidney Infections *

Cancer/Leukima *

COVID 19 *

Diabetes *

Eating Issues *

Endocrine/Gland/
Autoimmune Disease *

Headaches/Migranes *

Hepatitis or Liver Disease *

Learning/Developmental Issues *

Mononucleosis *

Overweight/Obese *

Pneumonia *

Rheumatic Fever, Heart Disease, Murmur *

Scoliosis *

Seizures *

Thyroid Disease *

Tuberculosis *

Ulcer/digestive Problems *

Any Mental Health Issues *

Any birth or congenital defects *

Any problems with teeth *

Any teeth causing pain? *

Any bleeding when brushing or flossing *

Dental cleaning within last 6 months *

Other

Allergies

Food Allergies *

Food Allergies Explained

Medication Allergies *

Medication Allergies Explained

Local Anesthetics or Latex *

Local Anesthetics explained

Does the patient have an Epi-Pen at School? *

Epi-Pen explained

Other Allergies

How did you hear about us?

About us(other)

Admin

Admin

Today

05-06-2025

Month

Add School

Behavioral Health Services Checkbox

Medical Service Checkbox

Dental Services Checkbox

R&RP Checkbox

Rights and Responsibilities Big Link

Click here to review the CHC Patient Rights and Responsibilities Document

Submit Button

Submit

Middle Name Formula

Preferred Language English n Spanish

Guarantor Relationship ES

Emergency Contact relationship ES

Patient Phone Type ES

Guarantor Phone Type ES

Emergency Contact Phone Type ES

Sexual Orientation

Gender Identity

Sexual Orientation (Other)

Gender identity (Other)

Gender identity (Other) [parent]

Gender identity (parent)

Related Campaign

Campaign - Record ID#

Medical Services Requested

Existing School?

237

School Name Parted

Button: Complete View

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Flu Check (SPA)2

Counseling Permission (SPA)

Dental Permission (SPA)

Provided info is accurate? (SPA)

Rights & Responsibilities (SPA)

How Did You Hear About Us? (SPA)

Parent Month of birth (SPA)

MH medical condition? (SPA)

MH any medications? (SPA)

MH Serious Injuries? (SPA)

MH ever been hospitalized? (SPA)

MH Surgery in the past? (SPA)

MH Shunts/Catheter? (SPA)

MH Was Teen Parent? (SPA)

MH Possibly Pregnant? (SPA)

MH Currently Nursing (SPA)

MH Dental Procedures? (SPA)

MH Smoke? (SPA)

MH Defects? (SPA)

CON Anemia/blood disorders (SPA)

CON Asthma (SPA)

CON Autism (SPA)

CON Bladder or kidney infections (SPA)

CON Cancer/leukemia (SPA)

CON Chicken pox (SPA)

CON Diabetes (SPA)

CON Eating issues (SPA)

CON Endocrine/gland disease/autoimmune disease (SPA)

CON Headaches/migraines (SPA)

CON Hepatitis or liver problems (SPA)

CON Learning/developmental issues (SPA)

CON Mononucleosis (SPA)

CON Overweight/obesity (SPA)

CON Pneumonia (SPA)

CON Rheumatic fever, heart disease, murmur (SPA)

CON Scoliosis (SPA)

CON Seizures (SPA)

CON Thyroid disease (SPA)

CON Tuberculosis (SPA)

CON Ulcer/digestive problem (SPA)

CON Any mental health issues? (SPA)

CON Any birth or congenital defects (spina bifida, brain, heart, lung, etc.)? (SPA)

CON Any problems with teeth? (SPA)

CON Any teeth causing pain? (SPA)

CON Any bleeding when brushing or flossing? (SPA)

CON Had a dental cleaning within the last 6 months? (SPA)

CON Other (SPA)

ALL Any foods? (SPA)

ALL Any Medications? (SPA)

ALL Any anesthetics? (SPA)

ALL Epi-Pen at school? (SPA)

ALL Other (SPA)

BEH Family changes (SPA)

BEH School issues (SPA)

BEH Social/peer stresses (SPA)

BEH Anxiety (SPA)

BEH Learning disabilities (SPA)

BEH Anger issues (SPA)

BEH Attention difficulties (SPA)

BEH Sadness and/or mood swings (SPA)

BEH Truancy/school avoidance (SPA)

BEH Recent loss (SPA)

BEH Counseling? (SPA)

Medical Insurance Address

Dental Insurance Address

Medicaid ID #

Race (SPA)

Ethnicity (SPA)

School Medical permission (SPA)

ALL Egg Allergy (SPA)

Flu OtherAll (SPA)

SeriousFlu (SPA)

Flu GBS (SPA)

Flu Vaccine30day SPA)

Flu Asthma (SPA)

Flu Aspirin (SPA)

Flu WeakImmune (SPA)

Flu Pregnant (SPA)

Flu WeakImmArea (SPA)

Insurance Check 2 (SPA)

Behavioral Health Message

Please complete ONLY if Patient is in need of Behavioral Health Services.

Button: View Spanish Form

Version en Espa�ol

School - Record ID#

Gender Identity Combined

Spanish Form?

Accuracy Verification Combined

Flu Check Combined

ROI/Payment Combined

HIE Combinded

Month of Birth Combined

Student Primary Language Combined

Race Combinded

Ethnicity Combined

Parent Phone Type Combined

Sexual Orientation Combined

Insurance Check Combined

Student Cell Validator Combined

Insurance Check 2 Combined

Insurance Type Combined

Policy Holder Month Of Birth Combined

Policy Holder Sex Combined

Secondary Insurance Check Combined

Secondary Insurance Type Combined

Secondary Policy Holder Sex Combined

Secondary Policy Holder Birth Month Combined

18attest Combined

Relationship to Patient Combined

Parent/Guardian Primary Language Combined

Parent Cell Validator Combined

<b><div style="color:red;"> Please enter a valid mobile phone number below</div></b>

Parent Email Validator Combined

<b><div style="color:red;"> Please enter your email address</div></b>

EC Relationship Combined

EC Phone Type Combined

EC Phone Validator Combined

<b><div style="color:red;"> Please enter a valid mobile phone number below</div></b>

Medicatons Combined

Medical Condition Combined

Injuries Combined

Defects Combined

Hospitalized Combined

Surgery Combined

Teen Parent Combined

Shunts Combined

Pregnant Combined

Nursing Combined

Dental Procedures Combined

Tobacco Combined

Anemia Combined

Asthma Combined

Autism Combined

Bladder Combined

Cancer Combined

Diabetes Combined

Eating Issues Combined

Endocrine Combined

Headaches Combined

Liver Problems Combined

Learning Issues Combined

Mononucleosis Combined

Obesity Combined

Pneumonia Combined

Rheumatic Combined

Scoliosis Combined

Seizures Combined

Thyroid Combined

Tuberculosis Combined

Ulcer Combined

Mental Health Issues Combined

Spine Bifida Combined

Teeth Problems Combined

Teeth Causing Pain Combined

Bleeding Teeth Combined

Dental Cleaning Combined

Allergies Combined

Medication Allergies Combined

Anesthetics Allergies Combined

Epi Pen Combined

BEH Enrollment Combined

BEH Counseling Combined

BEH Family Changes Combined

School Challenges Combined

Social Pressures Combined

Anxiety Combined

Learning Disability Combined

Anger Issues Combined

Sadness Combined

Attention Difficulties Combined

Truancy Combined

Recent Loss Combined

Flu Egg Combined

Flu Other Combined

Serious Flu Combined

GBS Combined

Vaccine 30day Combined

Asthma2 Combined

Flu Asprin Combined

Flu Weak Immune Combined

Flu Preg Combined

Flu Weak Immune Area Combined

Patient Sex Combined

Antibiotics for Dental Cobmined

Emergency Contact Relationship Combined

Emergency Contact Phone Type Combined

CHC Check Filter (SPA)

Students Grade (SPA)

Medical Specialist (SPA)

Heart Problems (SPA)

Hospitalized Over Night (SPA)

Dental Cleaning within last 6 Months (SPA)

Food Allergies (SPA)

Medication Allergies (SPA)

Patient Phone Type (SPA)

Emergency Contact Phone Type (SPA)

Local Anesthetics or Latex (SPA)

Covid 19 (SPA)

R&RP Combined

American Ind or Alaska details

Asian details

Black or African details

Hispanic or Latino details

Middle Eastern or African details

Native Hawaiian or Pacific details

White details

Ethnicity = Asian

Ethnicity = White

Ethnicity = American Indian or Alaska Native

Ethnicity = Black or African American

Ethnicity = Hispanic or Latino

Ethnicity = Middle Eastern or North African

Ethnicity = Native Hawaiian or Pacific Islander

Insurance Type 2

Ethnicity Other

Show Ethnicity Other

SBHC Logo

CONNIE Acknowledgment

Consents and Policies Acknowledgment

Parent M.I.

Emercency Contact M.I.

Secondary Policy Holder's M.I.

Emergency Contact Email Address

EC Email Validiator

Please enter your email address

EC Email Confirm

Language Other

Policy Holder's Relationship

Dental Provider's Phone

Dental Policy Holder Name

P/C Insurance Name

P/C Insurance Co Address

P/C Policy Holder Name

P/C Policy Holder DOB

P/C Policy Holder's Relationship

Dental Insurance Type

Dental Insurance = Medicad/Husky

Dental Insurance = Private/Commercial

Md/Bh Medicad/Husky Insurance ID #

Md/Bh - P/C Company Address

Md/Bh - P/C Policy Holder Name

Md/Bh - P/C Policy Holder Date of Birth

Md/Bh - P/C Policy Holder's Relationship to Patient

Student's Last Name2

Student's First Name2

Student's Middle Initial

Student's DOB

Parent Legal Guardian's Name

Parent Legal Guardian Daytime Phone Number

Insurance Name

Insurance ID #

Dose of Covid-19 vaccine

Complete Covid-19 vacciene series

Covid Vaccine record card

Allergic reaction

Allergic reaction options

Other Vaccine Allergic reaction

Student questions

Insurance Contains Dental and Medicaid

Decline Medical Services

Decline Behavioral Health Services

Decline Dental Services

Medical Services Required

Behavorial Services Required

Dental Services Required

Flu Consent Message

Would you like your child to receive their flu vaccine with a School Based Health Center staff?

Vaccine product

Vaccination record card

Reaction Type

Signature Name

Signature Date

Parent present for child vaccine

Logo

EC Email Validator(SPA)

Por favor, ingrese su direcci�n de correo electr�nico.

Insurance Covid check

Phone Confirm Message

EC Email Confirm Message

EC Phone Confirm Message

Medical and Dental Services not Available

Medical and Dental Services Declined

Hide Medical history

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Students Full Name

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