Student Patient Registration Form Student Patient Registration Form Dear Parent or Guardian: Aaron E. Henry Community Health Services Center, Inc. (AEHCHC) will be providing Early Periodic Screening, Diagnosis and Treatment (EPSDT). Medical and dental services for children and adolescents are offered through our school-based clinics, which include: Complete Physical Assessments, Wellness Exams, & Sports Physicals Vision Screening Hearing Screening Dental Assessment, Treatment, and Referral Developmental Assessments, Evaluations, and Referral for Treatment Parent and Child Health Education Referral Services Would you like your child to be assessed by Aaron E. Henry Community Health Services Center, Inc.? * Yes No Name of School * Clarksdale Municipal School District Coahoma County Schools Clarksdale Collegiate Public Charter School Lee Academy High School St. Elizabeth Catholic School Presbyterian Day School Coahoma Community College Madison Palmer Quitman County Schools Delta Academy North Panola School District South Panola School District North Delta School Tate County Schools Magnolia Heights School Hillcrest Academy Tunica County Schools Tunica Academy East Tallahatchie School District West Tallahatchie Schools Student Name * Student Name First First Last Last Student Address * Student Address Student Address Student Address City City State/Province State/Province Alabama Alaska Arkansas Arizona California Colorado Connecticut Delaware District of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming State/Province Zip/Postal Zip/Postal Student Date of Birth Student Social Security Number Student Gender Identity * Male Female Transgender Male (Female to Male) Transgender Female (Male to Female) Choose Not To Disclose Student Race/Ethnicity * Black /African-American White Hispanic/Latino Other Student's Language * English Spanish Other How does your child learn best? Verbally Written Material Demonstration Parent/Guardian/Caretaker Name * Parent/Guardian/Caretaker Name First First Last Last Parent/Guardian Cell Phone Number * Parent/Guardian Home Phone Number Parent/Guardian Work Phone Number Parent/Guardian Email Address Does your child need an interpreter? Yes No Relationship to Student * Parent/Guardian Date of Birth * Emergency Contact Name * Emergency Contact Name First First Last Last Emergency Contact Phone Number * Additional Contact Number Relationship to Student * Family Health History: To the best of your knowledge, does anyone in your child’s family have the following conditions? (Check which applies) * Heart Attack Heart Disease High Blood Pressure Stroke Cancer Diabetes Sudden Death Sickle Cell Anemia Nervous/Mental Problems Kidney Disease Seizures Disorder Arthritis None of these apply Child's Health History: Does your child have the following: (Check which applies) * Chicken Pox Asthma Communicable Disease Meningitis/Encephalitis Tonsillitis High Blood Pressure Heart Disease/Heart Murmur Respiratory Disease Kidney Disease Thyroid Disease Seizures (fits/convulsions) Major Injuries Behavior Problems Speech Problems Diabetes Birth Defects Sickle Cell Disease Sickle Cell Trait Eating Problems Allergy to Novocain or Dental Anesthesia None of these apply Please list any food or drug allergies your child has. Please list any medications your child is currently taking. Name of Insurance Provider and Policy Number * Upload a copy of your insurance card. If you are unable to upload, you will need to bring the card to the school-based clinic. Drop a file here or click to upload Choose File Maximum upload size: 268.44MB Name and Address of Pharmacy * All physicals in the schools are unclothed, appropriately draped with clinic gown and with a chaperone present. Do you consent to an unclothed exam? * Yes No No, I prefer that my child have clothed exam only Lead Poisoning Risk Assessment. Answer ONLY IF YOUR CHILD IS 6 YEARS OLD OR YOUNGER. Check each box for YES or check NONE (if the answer is NO for all). Does your child live or regularly visit a house or building built before 1960? (Including a daycare center, preschool, the home of babysitter or relative, or friend’s house) Does this house or building have chipping or peeling paint? Is this house or building being, or has it recently been renovated or remodeled? Does your child have a brother, sister, housemate, or playmate being monitored or treated for lead poisoning? Does your child live with or come in frequent contact with an adult whose job involves exposure to lead, such as pottery, ceramics etc.? Does your child live near an active lead smelter, battery recycling plant, or other industry likely to release lead? Do you give your child any folk remedies that might contain lead? Does your child live near a heavily traveled highway where soil / land/ dirt may be contaminated with lead? ( Are you aware of any lead contamination in your water supply from outdated plumbing? No/None What is your current living arrangement? * Own/Rent Homeless Shelter Transitional Housing Doubling Up Currently Living on the Street How Many People are Living in Your Household? 1 2 3 4 5 6 7 8 9 10 or more Household Size List all the people who live in your household. To add one person, click the "Add Person" button. To remove one person, click the "Remove Person" button. Name of Person Living with You Name of Person Living with You First First Last Last Relationship to You Age Yearly Income $.00 Yearly income from a job, SSI, etc. Upload Proof of Income Drop a file here or click to upload Choose File Maximum upload size: 268.44MB Add Person Remove Person I, the patient or parent/guardian, hereby authorize any holder of information about me or any information needed for settlement of claims to be released to Medicaid, Medicare, or Insurance Provider. I understand approved claims will be deducted from my allocated benefits whether they were rendered in one pf our clinics or mobile health family. I request that all health insurance benefit payments be made on my behalf to Aaron E. Henry Health Services Center, Inc.. Having registered with AEHCHC, I, the undersigned patient or responsible person, understand that this registration form is valid and services will continue as long as I or my child is enrolled in this school or until I decide to opt-out by sending a written notice to discontinue services. My signature is my authorization to bill on my behalf. My signature also serves as authorization for service and treatment. I may provide a written notice to dismiss this authorization to AEHCHC at any time. Parent/Guardian Signature * Clear By electronically signing your signature, you are agreeing that you have read and understood the above and consent to submit your application electronically. Today's Date If you are human, leave this field blank. Submit
