School Telehealth Patient Information Form

Patient Information

Enter nine-digit SSN

* Child's Gender Identity





Enter State two-digit Abbrieviation: TX
Enter Zip Code Format: 12345
School Information
Race/Ethnicity (Select Appropriate Group)
Medical Allergies
Medical history

Pharmacy & Primary Care

Format: 2141231234

Parent/Guardian Information

Child lives with:

Format: Example@example.com
Click Checkbox to Opt out of Email from Children's Health
Format: 2141231234
Format: 2141231234

Emergency Contact

Format: 2141231234

Children's Health Medical Group may disclose medical and billing information to this contact

Insurance Information

* Please Select the type of insurance for the patient

Format: 2141231234

* Guarantors Relationship to Child

* Guarantor Address Same as child?

Signer

NOTICE CONCERNING COMPLAINTS

Complaints about physicians, as well as other licensees and registrants of the Texas Medical Board, including physician assistants, acupuncturists, and surgical assistants may be reported for investigation at the following address:

Texas Medical Board Attention: Investigations
1801 Congress Avenue, Suite 9.200
P.O. Box 2018
Austin, Texas 78768-2018

Assistance in filing a complaint is available by calling the following telephone number: 1-800-201-9353

For more information please visit our website at: www.tmb.state.tx.us