Healthcare Youth Intake Packet

HEALTHCARE YOUTH INTAKE PACKET

Youth Patient Information

Patient Full Legal Name:

Date of Birth:

Parent / Guardian Information

Emergency Contact

Insurance Information

Medical History

Is the patient up-to-date on immunizations? Yes No

Consent for Treatment & Authorizations

I hereby authorize licensed providers and clinical staff of this practice to provide medical assessment, diagnostic testing, routine care and treatment indicated for the minor named above. This authorization includes emergency medical care deemed necessary to preserve life and prevent serious harm when I cannot be reached. I understand that I may withdraw this consent at any time by providing written notice to the practice; withdrawal will not affect any treatment provided prior to receipt of the notice.

Authorization Expiration Date:

HIPAA / Release of Information

I acknowledge receipt of the practice's Notice of Privacy Practices. I authorize the release of medical information necessary for treatment, payment and healthcare operations and to the persons or entities listed below for purposes related to the care of the patient. This authorization shall remain in effect until the date specified above or until revoked in writing.

I understand that I may revoke this authorization at any time by submitting written notice, except to the extent that action has already been taken in reliance on this authorization.

Medication Administration / School Permissions

I permit clinical staff or designated school personnel to administer prescribed medications and to provide over-the-counter medications as indicated below during authorized encounters.

Photograph and Video Consent

I authorize the use of photographs or video recordings of the patient for treatment documentation, educational purposes, or internal quality improvement. I understand that identifying information will be protected in accordance with privacy laws.

Consent to photograph/video Do not consent

Certification and Acknowledgment

By signing below, I certify that the information provided in this intake packet is true and complete to the best of my knowledge. I understand the nature and limits of the authorizations granted herein, the right to revoke authorizations, and the practice's responsibilities regarding privacy and emergency care. I accept financial responsibility for services provided to the patient in accordance with the practice's billing policies.

Sign Now