Consent for Health Services & Emergency Treatment

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Consent for Health Services & Emergency Treatment
I, ________________________hereby give my consent for the child listed below to receive the screening tests and examinations checked below, and for transport of the child to and from the services as needed. I understand these services are deemed necessary or advisable by the Head Start program and that I will be informed of any results that are not normal.

I also understand that is my responsibility to provide Head Start with an up-to-date immunization record and a record of medical and dental examinations performed in the past year. This consent is valid for one year after the signed date. The purpose of this consent has been explained to me. I agree:

That in case of emergency or if a parent or guardian cannot be contacted, Head Start may provide first aide or emergency medical care if needed. __________Yes __________ No
Please Initial Below:

Developmental Screening

Dental Examination/Screening

Medical Examination (If necessary)

Height & Weight

Speech Screening

Vision Test

Hearing Test

T.B. Test

Immunizations (if necessary)

Lead Test (I understand this test involves a blood sample by “fingerstick” or venipuncture if necessary)

Brush teeth daily with fluoride

Emergency First Aide Treatment

Mental Health Screening

Planned Program Field Trips

Use of my child’s photograph in any Head Start related activity or materials

Crisis Counseling

Follow-up Treatment/Screening (if necessary)

Any Further Diagnostic Testing (if necessary)

Medical Home Please List: (Example- I.H.S., Northern Mt Hospital, Etc.)

Dental Home Please List: (Example-I.H.S. Dental, Havre Dental Group, Etc.)

As a parent/guardian of, _________________________ I hereby authorize the release of Medicaid/THSTEPS eligibility information and medical records to satisfy Head Start requirements.

CHILD’S NAME:_________________________ DATE OF BIRTH: _____________________
Signature of Mom or Dad/Guardian: ________________________________________________
Relationship to Child: ____________________ Date: ____________________

I have explained to the purpose of this release and the nature of the tests and examinations that the children enrolled in Head Start receive.

Signature of Head Start Staff: ____________________ Date: _____________________

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