School Based Health Center - Parental Consent Forms 

School-based healthcare can serve students differently, based on need. Statistics show that teens are the least likely to get the recommended health services. Medical services include immunizations, sports/work/annual physicals, asthma or other chronic disease management and acute care for sick or injured students. Mental Health services will be based on unique client need. Vision services will include comprehensive eye examinations and the prescribing and dispensing of corrective lenses if necessary. Dental services will include preventative exams, cleanings, x-rays and corrective treatment as needed.


Printable Form:
English,  Spanish


Printable Form:
English,  Spanish

Consent forms can also be picked up at each school as well as each School Based Health Center

Services will not be provided without parental consent 

Registration/History Forms

New patients will be required to fill out a Registration and Medical History form when they arrive.  If applicable, you are welcome to print the forms prior to your appointment and bringing the completed forms with you at the time of the appointment.  See printable forms below.

      Registration - English, Spanish

      Adult Medical History - English, Spanish

      Pediatric Medical History - English, Spanish

Medical Release Form

Whether records are for the patient’s personal use or being released to a third party by the patient, a Medical Release Form must be completed.  

Medical Release Forms - English, Spanish   

Once a Medical Release Form has been properly completed and returned to your provider, please allow 5 to 7 business days to process your request, as the information may not be onsite.  Keep in mind, each health care facility in Ohio must maintain records for six (6) years from the date of discharge, documenting the patient’s needs and assessments and services rendered.  Please contact the office to confirm your records still exist, if they exceed the legal required time frame.

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