Policy & Program


School-Based Health Centers - Implementation Tools
WAYNE INITIATIVE FOR SCHOOL HEALTH (WISH)

PARENTAL PERMISSION FORM

Note: This information will be valid for one year

Student

 Date of Birth
Social Security #

Address

City

 State

 Zip

School

 Grade

Parent/Legal Guardian
Address

Home Phone

 Work Phone

Employer
Employer Address

Child's Physician

 Phone Number

MEDICAL HISTORY
**To be completed by parent/legal guardian.

Has your child had a physical complete exam in the last 12 months? (Not a sick visit )
If no, when was his/her last physical exam ?
When was your child's last tetanus booster?
Name of doctor or facility where given

Is there a history of: (Circle One)

A. Birth deformities (one Eye, one kidney, etc.)

 YES NO
B. Known past illness more than two weeks in duration

 YES NO
C. Medical conditions currently under treatment

 YES NO
D. Fractures or disabling injuries

 YES NO
E. Any permanent disability

 YES NO
F. Allergy (drug, food, clothing)

 YES NO
G. History of convulsion, seizure or fainting

 YES NO
H. Hospitalization for any reason

 YES NO
I. Mental disorder

 YES NO
J. Asthma or breathing problems

 YES NO
K. Heart or blood problems

 YES NO
L. Headaches, eye, or ear problems

 YES NO
M. Stomach or kidney problems

 YES NO
N. Serious behavior problems

 YES NO
O. Other health concerns

 YES NO
P. Drug or alcohol use

 YES NO
Q. Sexually transmitted disease

 YES NO

Please explain any "yes" answers

.

EMERGENCY TREATMENT

A. An emergency exists if, in the judgment of the Nurse Practitioner or Registered Nurse, treatment is immediately required to prevent deterioration or worsened patient condition.

B. A minor may sign a request for treatment without the parent's consent if an emergency exists.

C. Emergency care outside the defined scope of services of WISH will be referred to appropriate agencies.

D. In emergency situations requiring acute care, WISH personnel will contact the Emergency Medical System for transport of the student to the appropriate medical facility.

In case of an emergency, who should we contact? Please list at least two contacts.


Name
 Phone #
 Relationship to Student
1.


2.




As the parent or legal guardian of _____________________________________________, I hereby give my permission for medical diagnosis and treatment and certify that the medical history above is accurate to the best of my knowledge.

Student Signature

Parent/Guardian (please print)


Parent/Guardian Signature

Date



Reimbursement Information

Reimbursement for services will be the same as any doctor's of advice. We will accept Medicaid, Private Insurance, and, if necessary, you may pay according to our sliding fee scale which is based on your yearly income and the number of people in your household. Please check the appropriate form of payment.

Medicaid (We MUST make a copy of the most recent card)
Insurance (We MUST make a copy of the card)
Self Pay
 (Most recent W2 form or your last pay check stub is Required)
***For Self Pay only***** Number of individuals claimed on last W2 * * * * ____________.

Please send your insurance card, Medicaid card, or verification of income by your child so that we can make a copy for your child's file.
We will immediately return the card to your child. Please include a copy of an updated immunization record if available.

We would appreciate your returning this completed form and any other necessary information to the WISH Health Center.
Thank you for your support.

SERVICES OFFERED

On-Site
  • Medical evaluation, with history, physical examination, and routine office lab tests
  • Treatment of injures and acute illness
  • Counseling, assessment, consultation and referral to appropriate services
  • Substance abuse prevention and intervention
  • Pregnancy prevention
  • Immunization (tetanus booster)
  • Social work services
  • Gynecological services and education. This does not include prescription and dispensing of
    contraceptives (including condoms). The program is based on abstinence.
  • Selected prescription and nonprescription medications
  • Nutritional services
  • Mental Health i.e. counseling and education
  • Health Education Services

Off-Site


  • Referrals if appropriate to medical or dental specialists
  • X-ray and special laboratory services, when appropriate
  • Selected prescription and nonprescription medications not available through the health center
  • Other appropriate treatments when indicated

Laboratory Tests and Other Services

I. Laboratory Tests - (performed in a family physicians office) including:

  • Urinalysis
  • Diabetic screening
  • Strep throat culture
  • Hematocrit/hemoglobin (blood test)
  • Others such as: KOH prep for fungi; fluorescent lamp diagnosis; microscopic exam for lice, etc.
  • Mononucleosis rapid testing (monospot)

Special Note:

In addition, we will perform the following tests, if requested, under North Carolina General
Statute 90-21.5 which allows minors to give consent for certain medical/health services:

  • Gram stain, gonorrhea culture; genital herpes culture
  • Pregnancy test
  • Microscopic testing for specific and nonspecific vaginitis
  • Pap smear
*North Carolina General Statute 90-21 5 allows minors to give consent for certain medical/health services

II. Complete Physical Examination/Specific Areas

  • Height/weight - nutritional assessment
  • Eyes - vision screening, muscle balance, etc.
  • Ears - hearing screening, ear canals, etc.
  • Mouth - teeth, gums, throat, etc.
  • Musculoskeletal evaluation
  • Neurological evaluation
  • Cardiovascular - blood pressure screening, heart auscultation
  • Skin - acne, ringworm, etc.
  • Genitalia examination
  • Head and necl; examination


General Assembly of North Carolina
Session 1977
Ratified Bill
Chapter 582
House Bill 370

AN ACT TO AUTHORIZE HEALTH SERVICES FOR MINORS

The General Assembly of North Carolina enacts:
Section 1. G.S. 90-21.4 is hereby rewritten to read as follows:

" 90-21.4 Responsibility, liability and immunity of physicians---

(a) Any physician licensed to practice medicine in North Carolina providing health services to a minor under the terms, conditions and circumstances of this Article shall not be held liable in any civil or criminal action for providing such services without having obtained permission from the minor's parent, legal guardian, or person standing in loco parentis. The physician shall not be relieved on the basis of this Article from liability for negligence in the diagnosis and treatment of a minor.
(b) The physician shall not notify a parent, legal guardian, or person standing in loco parentis without the permission of the minor, concerning the medical health services set out in G.S. 90-21.5(a), unless the situation in the opinion of the attending physician indicates that not)fication is essential to the life or health of the minor. If a parent, legal guardian or person standing in loco parentis contacts the physician concerning the treatment or medical services being provided to the minor, the physician may give information."

Sec. 2. G.S. 90-21.5 is hereby rewritten to read as follows:

" 90-21.5. Minors consent aufficient for certain medical health services.--- a) Any minor may
give effective consent to a physician licensed to practice medicine in North Carolina for medical health services for the prevention, diagnosis and treatment of (l) venereal disease and other diseases reportable under G.S. 130-81 (1 1) pregnancy (111) abuse of controlled substances or alcohol, and (1V) emotional disturbance. This section does not authorize the inducing of an abortion, performance of a sterilization operation, or commitment to a mental institution of hospital for confinement or treatment of a mental condition. (h) Any minor who is emancipated may consent to any medical treatment, dental and health services for himself of for his child."

I have read the Ratified Bill To Authorize Health Services for Minors and fully understand its contents.

Parent or Legal Guardian

Date