KDOW Updated Consent Form

Please complete all information on this permission form. Please COMPLETE then sign and date it in order for your child to continue services from Kids’-Doc-On-Wheels, Inc. Please notify us immediately of any changes in address, phone numbers and/or insurance.

Date

Patient's Name (Last)

Middle

First Name

Address

Apt. Number

City

State

Zip

Home Phone Number

Mother's Work Phone

Father's Work Phone

Cell Phone Number

Emergency Name

Phone Number

Relationship to Patient

Birth Date

If Other, please specify

Social Security Number

School

Grade

Pharmacy Name and Address

Phone Number

Insurance Information

No Insurance

Add new row

You may be eligible for Medicaid if not currently receiving it. Would you be interested in someone contacting you regarding this insurance?

Yes No

Updated Health Information

Any new Medical Conditions (physical, behavioral health, dental)

Yes No

If Yes, please list

Any new Allergies (medications, food, environmental)

Yes No

If Yes, please list

Is your child currently being seen for Behavior Health or Mental Health?

Yes No

If yes, who is the Provider

Dental Appointment in the past year

Yes No

If Yes, Date Seen

I hereby give consent for my child to continue to receive medical, behavioral health and dental services (when available) from

Kids’-Doc-On-Wheels, Inc. I authorize any physician, physician-designated health professional, dentist or behavioral health provider working for the clinic to provide such medical tests, procedures, treatments and assessments as are reasonably necessary or advisable for the evaluation and management of my child’s health care.

DISCLAIMER: By typing your name below, you are signing this application electronically. You agree that your electronic signature is the legal equivalent of your manual signature on this application.

Name Signature of Parent/Legal Guardian

Relationship to Patient

Date

Photo Release

By signing below, I hereby grant Kids'-Doc-On-Wheels, Inc. the right to take, edit, alter, copy, exhibit, publish, distribute and make use of any and all pictures of me or my child publicly to be used in and or for any lawful promotional materials including, but not limited to, newsletters, flyer's, posters, brochures, advertisements, fundraising letters, annual reports, press kits and submissions to journalists, websites, social networking sites, and other print and digital communications without payment or any other consideration. I understand that photos for distribution will not take place at any time during my child's physical examination. I understand that no royalty, fee, or other compensation shall become payable to me by reason of such use. I waive any right to royalties or other compensation arising or related to the use of the photograph. I understand and agree that these materials shall become the property of Kids'-Doc-On-Wheels, Inc. and will not be returned.

DISCLAIMER: By typing your name below, you are signing this application electronically. You agree that your electronic signature is the legal equivalent of your manual signature on this application.

Yes, I consent to photos. Signature:

No, I do not consent to photos. Signature:

Your information will be encrypted.

KDOW Updated Consent Form

Insurance Information

Updated Health Information

Photo Release

Kids Doc on Wheels!