Note: This information will be valid for one year


Date of Birth

Social Security #











Parent/Legal Guardian



Home Phone

Work Phone



Employer Address


Child’s Physician

Phone Number


**To be completed by parent/legal guardian.

Has your child had a physical complete exam in the last 12 months? (Not a sick visit )

If no, when was his/her last physical exam ?

When was your child’s last tetanus booster?

Name of doctor or facility where given


Is there a history of: (Circle One)

A. Birth deformities (one Eye, one kidney, etc.) YES NO
B. Known past illness more than two weeks in duration YES NO
C. Medical conditions currently under treatment YES NO
D. Fractures or disabling injuries YES NO
E. Any permanent disability YES NO
F. Allergy (drug, food, clothing) YES NO
G. History of convulsion, seizure or fainting YES NO
H. Hospitalization for any reason YES NO
I. Mental disorder YES NO
J. Asthma or breathing problems YES NO
K. Heart or blood problems YES NO
L. Headaches, eye, or ear problems YES NO
M. Stomach or kidney problems YES NO
N. Serious behavior problems YES NO
O. Other health concerns YES NO
P. Drug or alcohol use YES NO
Q. Sexually transmitted disease YES NO


Please explain any “yes” answers




A. An emergency exists if, in the judgment of the Nurse Practitioner or Registered Nurse, treatment is immediately required to prevent deterioration or worsened patient condition.

B. A minor may sign a request for treatment without the parent’s consent if an emergency exists.

C. Emergency care outside the defined scope of services of WISH will be referred to appropriate agencies.

D. In emergency situations requiring acute care, WISH personnel will contact the Emergency Medical System for transport of the student to the appropriate medical facility.

In case of an emergency, who should we contact? Please list at least two contacts.

Name Phone # Relationship to Student



As the parent or legal guardian of _____________________________________________, I hereby give my permission for medical diagnosis and treatment and certify that the medical history above is accurate to the best of my knowledge.


Student Signature

Parent/Guardian (please print)


Parent/Guardian Signature


Reimbursement Information

Reimbursement for services will be the same as any doctor’s of advice. We will accept Medicaid, Private Insurance, and, if necessary, you may pay according to our sliding fee scale which is based on your yearly income and the number of people in your household. Please check the appropriate form of payment.

Medicaid (We MUST make a copy of the most recent card)
Insurance (We MUST make a copy of the card)
Self Pay (Most recent W2 form or your last pay check stub is Required)

***For Self Pay only***** Number of individuals claimed on last W2 * * * * ____________.

Please send your insurance card, Medicaid card, or verification of income by your child so that we can make a copy for your child’s file.
We will immediately return the card to your child. Please include a copy of an updated immunization record if available.

We would appreciate your returning this completed form and any other necessary information to the WISH Health Center.
Thank you for your support.



  • Medical evaluation, with history, physical examination, and routine office lab tests
  • Treatment of injures and acute illness
  • Counseling, assessment, consultation and referral to appropriate services
  • Substance abuse prevention and intervention
  • Pregnancy prevention
  • Immunization (tetanus booster)
  • Social work services
  • Gynecological services and education. This does not include prescription and dispensing of
    contraceptives (including condoms). The program is based on abstinence.
  • Selected prescription and nonprescription medications
  • Nutritional services
  • Mental Health i.e. counseling and education
  • Health Education Services


  • Referrals if appropriate to medical or dental specialists
  • X-ray and special laboratory services, when appropriate
  • Selected prescription and nonprescription medications not available through the health center
  • Other appropriate treatments when indicated

Laboratory Tests and Other Services
I. Laboratory Tests – (performed in a family physicians office) including:

  • Urinalysis
  • Diabetic screening
  • Strep throat culture
  • Hematocrit/hemoglobin (blood test)
  • Others such as: KOH prep for fungi; fluorescent lamp diagnosis; microscopic exam for lice, etc.
  • Mononucleosis rapid testing (monospot)

Special Note:
In addition, we will perform the following tests, if requested, under North Carolina General
Statute 90-21.5 which allows minors to give consent for certain medical/health services:

  • Gram stain, gonorrhea culture; genital herpes culture
  • Pregnancy test
  • Microscopic testing for specific and nonspecific vaginitis
  • Pap smear

*North Carolina General Statute 90-21 5 allows minors to give consent for certain medical/health services
II. Complete Physical Examination/Specific Areas

  • Height/weight – nutritional assessment
  • Eyes – vision screening, muscle balance, etc.
  • Ears – hearing screening, ear canals, etc.
  • Mouth – teeth, gums, throat, etc.
  • Musculoskeletal evaluation
  • Neurological evaluation
  • Cardiovascular – blood pressure screening, heart auscultation
  • Skin – acne, ringworm, etc.
  • Genitalia examination
  • Head and necl; examination

General Assembly of North Carolina
Session 1977
Ratified Bill
Chapter 582
House Bill 370


The General Assembly of North Carolina enacts:
Section 1. G.S. 90-21.4 is hereby rewritten to read as follows:

” 90-21.4 Responsibility, liability and immunity of physicians—

(a) Any physician licensed to practice medicine in North Carolina providing health services to a minor under the terms, conditions and circumstances of this Article shall not be held liable in any civil or criminal action for providing such services without having obtained permission from the minor’s parent, legal guardian, or person standing in loco parentis. The physician shall not be relieved on the basis of this Article from liability for negligence in the diagnosis and treatment of a minor.
(b) The physician shall not notify a parent, legal guardian, or person standing in loco parentis without the permission of the minor, concerning the medical health services set out in G.S. 90-21.5(a), unless the situation in the opinion of the attending physician indicates that not)fication is essential to the life or health of the minor. If a parent, legal guardian or person standing in loco parentis contacts the physician concerning the treatment or medical services being provided to the minor, the physician may give information.”

Sec. 2. G.S. 90-21.5 is hereby rewritten to read as follows:

” 90-21.5. Minors consent aufficient for certain medical health services.— a) Any minor may
give effective consent to a physician licensed to practice medicine in North Carolina for medical health services for the prevention, diagnosis and treatment of (l) venereal disease and other diseases reportable under G.S. 130-81 (1 1) pregnancy (111) abuse of controlled substances or alcohol, and (1V) emotional disturbance. This section does not authorize the inducing of an abortion, performance of a sterilization operation, or commitment to a mental institution of hospital for confinement or treatment of a mental condition. (h) Any minor who is emancipated may consent to any medical treatment, dental and health services for himself of for his child.”

I have read the Ratified Bill To Authorize Health Services for Minors and fully understand its contents.

Parent or Legal Guardian