Healthcare Child Orientation Form

Healthcare Child Orientation Form

Child Information

Male   Female   Other   Prefer not to say

Insurance Information

Medical History

No known allergies   Food   Drug   Environmental   Other

Immunizations up to date?
Yes   No

Orientation Topics — Acknowledgment

By signing below I acknowledge that a staff member provided an orientation covering the items listed and I understand the policies, procedures, and my responsibilities as the parent/legal guardian.

Facility policies, check-in/check-out procedures, and visitation rules
Medication administration procedures and required authorizations
Emergency procedures, first aid, and when emergency services will be called
Infection control and hygiene practices
Privacy practices and release of information (HIPAA)
Behavior expectations and safety rules

Consents and Authorizations

I authorize facility staff to provide routine, non-invasive care necessary during visits including vital signs, weight/height, and basic comfort measures. I understand that separate written consent is required for invasive procedures.

I authorize routine non-invasive care as described above

In the event of an acute emergency, I authorize facility staff to provide emergency first aid and to arrange transport to an emergency facility when, in the professional judgment of staff, it is necessary to protect the child's health. I understand attempts will be made to contact me immediately.

I authorize emergency first aid and emergency transport as described above

Medication administration: I understand that prescription medications will be administered only with a written order from the prescribing provider and appropriate parent/guardian authorization. Over-the-counter medications will be given only with explicit prior written authorization.

I understand medication administration requirements and will complete separate medication authorizations when necessary

Photography / Video

I understand the facility may document care for clinical, educational, or quality assurance purposes. Photographs or video for identification or treatment may be taken. I may limit or withhold permission for use beyond clinical record by indicating below.

I permit photography/video for clinical, educational, and quality improvement purposes (not for public release)
I do NOT permit photography or video beyond standard clinical documentation

Authorized Pickup & Release

List all persons authorized to pick up the child. Staff will require photo identification at pickup. The facility will not release the child to persons not listed below without prior written authorization.

Privacy Acknowledgment

I acknowledge that I have been informed of the facility's privacy practices and my rights regarding the child's protected health information. I authorize release of relevant medical information to the authorized persons listed above and to other health care providers involved in the child's care as necessary for treatment, payment, or healthcare operations.

I acknowledge receipt of privacy practices and authorize limited release as described

Authorization Duration & Withdrawal

This orientation acknowledgement and the consents granted herein will remain in effect until the Authorization Expiration Date below or until revoked in writing by the parent or legal guardian. Revocation does not affect actions taken by the facility prior to receiving notice of revocation.

Certification

I certify under penalty of perjury that the information provided on this form is true and correct to the best of my knowledge. I affirm that I am the parent or legal guardian authorized to make health care decisions for the child named above and that I have read, understand, and accept the orientation items, consents, and acknowledgments described in this document.

I certify that the information is accurate and that I am the parent/legal guardian authorized to sign

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