El Proyecto del Barrio Friends of the Family  Bridge Focus WRAP Family Services  Northridge Hospital Kaiser Permanente Valley Trauma Center  Child & Family Guidance Center  American Red Cross 

Chatsworth Healthy Start Collaborative Family Services Center

Consent Form

Name of Student: Grade: School:

Address: Birthdate :

Telephone:

I hereby request and consent to diagnostic procedures, tests and medical and dental treatment deemed advisable by the professional staff of any of the agencies listed above. I understand further that the services authorized by my signature on this form are for simple, common or routine health care services and treatment including:

  • Diagnosis and treatment of minor and acute illnesses
/
  • First aid for minor injuries

  • Assistance with chronic illnesses, such as asthma, diabetes, and epilepsy
/
  • Immunizations and TB skin tests
  • Prenatal care

  • Prescriptive and over-the-counter medications
/
  • Vision and hearing assessments

  • Physical Examinations
/
  • Pregnancy Testing

  • Routine lab tests, such as cultures, urinalysis, lead level
/
  • Diagnosis and treatment of sexually transmitted diseases

and anemia screening /
  • Dental preventive and treatment services

  • Mental health services, such as individual, group and family therapy
/
  • Health Education in diet, hygiene, preventive care, and other healthy lifestyle behaviors

Referrals will be provided for health care services that cannot be offered at the Family Services Center.

I hereby authorize a physician and other professional clinic staff to provide necessary and/or advisable treatment for the above student. This student has my permission to receive all services offered at the CHSFSC except those that I have specifically excluded above. Records will be kept in a confidential manner except in the case of danger to self or others.

I understand that no student or his/her family will be charged directly for services rendered at the CHSFSC. The CHSFSC may bill third party payment sources as appropriate. Other funds will be used to support services rendered to students without insurance or Medi-Cal. I further understand that the CHSFSC will assist patients in applying for any/all public/private funding sources to reimburse the CHSFSC for services provided.

Signature of Parent/Legal Guardian: Date:

Name of Parent/Legal Guardian: Relationship:

Home Phone: Work/Emergency Phone:

Health Insurance (Company & #) Medi-Cal #(If applicable)