School Telehealth Patient Information Form

2024-2025 School Telehealth Patient Information Form

Patient Information

* Child's Last Name

* Child's First Name

Child's Middle Name

* Child's Date of Birth

Child's Social Security # Enter nine-digit SSN

* Child's Gender Identity

Male
Female
Non-binary/Genderqueer
Decline to Answer

* Street Address

Address 2

* City

* State Enter State two-digit Abbrieviation: TX

* Zip Enter Zip Code Format: 12345

School Information

Race/Ethnicity (Select Appropriate Group)

Asian

Native American

Black/African

White/Caucasian

Latino/Hispanic

Other

Medical Allergies

PCN/Amoxicillan

Sulfa Drugs

Anticonvulsants

Cephalosporins (Omnicef)

NSAIDS (ibuprofen)

Other

Medical history

PE Tubes

Food Allergies

Poor Vision

Kidney Disease

Seasonal Allergies

Asthma

Heart Disease

Other Allergies

Pharmacy & Primary Care

* Preferred Pharmacy Name

* Cross Street / Address

* Pediatrician / PCP

* PCP Phone # Format: 2141231234

Parent/Guardian Information

Child lives with:

Father & Mother Father Mother Guardian/Other

* Parent/Guardian's Last Name

* Parent/Guardian's First Name

Parent/Guardian Middle Initial

* Parent/Guardian Date of Birth

* Email Address Format: Example@example.com

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* Primary Phone Number Format: 2141231234

Alternate Phone Number Format: 2141231234

Emergency Contact

Incase of Emergency, who should we contact?

* Emergency Contact Full Name

* Emergency Contact Phone Number Format: 2141231234

* Emergency Contact Relationship to Patient

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

Yes No

Insurance Information

* Please Select the type of insurance for the patient

Commercial Insurance CHIP Medicaid None

* Name of Person Responsible for Paying the Bill (guarantor)

* Guarantors Primary Phone Format: 2141231234

* Guarantors Date of Birth

* Guarantors Relationship to Child

Father Mother Other

* Guarantor Address Same as child?

Yes No

Signer

* Printed Name of Patient/Parent or Legally Authorized Representative

* Signer's Relationship to Patient

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

333 Guadalupe, Tower 3, Suite 610, P.O. Box 2018, MC-263 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