Mobile Health Patient Registration Form

Medical Associates Plus

Mobile Health Patient Registration Form
Child's Legal Name *

First Name Middle Inital Last Name
Date of Birth *

Month Day Year
Age *
Gender *

Male Female
Date *

Month Day Year
Date
Please Select School Level *

Elementary School Middle School High School Magnet School Special School
Elementary School
Middle School
High School
Magnet School
Special School
County *
Grade *
Teacher's Name *

Consent for Treatment
Do you consent to Dental treatment? *

Yes No
I am the parent/legal guardian of the minor child listed above. I consent to my child receiving Dental treatment, and allow the school nurse and Dental provider to view Dental records. I give Medical Associates Plus permission to treat my child and I have seen HIPAA right documentation.

Clear
Do you consent to Medical treatment? *

Yes No
I am the parent/legal guardian of the minor child listed above. I consent to my child receiving Medical treatment, and allow the school nurse and Dental provider to view Medical records. I give Medical Associates Plus permission to treat my child and I have seen HIPAA right documentation.

Clear
Should be Empty:

Medical Associates Plus