PARENTAL CONSENT FOR SCHOOL HEALTH SERVICES

Student Name

School

Teacher

Grade

WHAT IS THE SCHOOL HEALTH SERVICES PLAN?

This School Health Services Program is designed to appraise, protect and promote the health of our students as well as provide preventive and emergency school-based health services in accordance with the Whole School, Whole Community, Whole Child (WSCC) mode and the School Health Services Plan for Bay County

ESSENTIAL School Health Services & Screenings

Florida Statue 381.0056 mandates regular health screening to public school students. The screenings include vision, hearing, height and weight, Body Mass Index (BMI) and scoliosis (6th grade only). Vision exams provided by a Florida Board Certified Doctor of Optometry for all vision screening failures.

Yes, I agree to all essential screenings No, I decline all essential screenings Yes, to all except

Yes No

School Health Room Services

Basic First Aid Services
Assist student with physician ordered medication administration (BDS permission form required)

The above consent statements will remain in effect until the parent/legal guardian submits a new School Health Services Consent form

ADDITIONAL BDS School Health Services

The following health care services are also available through the District’s health care partner, PanCare of Florida, Inc. Please indicate your choice for each optional service.

Yes No

School Physicals

Physicals provided by a Florida Licensed Medical Provider

Yes No

Preventative Dental Services

Dental exams provided by a Florida Licensed Dentist
Dental cleanings provided by a Florida Licensed Dental Hygienist
Dental sealants applied to molars as needed by a Florida Licensed Dental Hygienist

Yes No

Vision Care Program

Eye exams provided by a Florida Board Certified Optometrist
If prescribed, opportunity to order eyeglasses at a discount
Eyeglass fitting and care instruction provided by a Florida Optician

Yes No

TeleHealth/Telemedicine Services

School health nurse connects student with PanCare (Florida Licensed) Medical Providers during a TeleHealth encounter
Diagnoses and treatment for acute illnesses and minor injuries such as strep throat, ear infections, rash, influenza, COVID 19, etc.
If needed, the health care provider can write a prescription and send it electronically to the family's pharmacy

STUDENT'S FIRST & LAST NAME:

Date of Birth

PARENT'S FIRST & NAME:

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

PARENT/LEGAL GUARDIAN SIGNATURE

Date

The above consent statements will remain in effect until the parent/legal guardian submits a new School Health Services Consent form.

Your information will be encrypted.