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Child and Family Agency

Child and Family Agency

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Forms – CBC Child Enrollment


Community Bridge Clinic Enrollment - Child

Patient Information

Full Legal Name of Person Receiving Services(Required)
MM slash DD slash YYYY
Address(Required)
Sex(Required)

Ethnicity(Required)
Race(Required)

Does the patient attend school?(Required)

Insurance Information

Do you have insurance (private/Medicaid/Husky)?(Required)
Insurance Address
Policy Holder Name(Required)
MM slash DD slash YYYY
Is there additional insurance?(Required)
Insurance address(Required)
Policy Holder Name(Required)
MM slash DD slash YYYY

Parent/Guardian Information

Parent/Guardian Name(Required)
MM slash DD slash YYYY
Address (if different from patient)
I agree voicemail messages can be left for me on:(Required)
Has your child seen this dentist/group for 1+ year(s)

Second Emergency Contact

Name

Medical History

MM slash DD slash YYYY
Does the patient have any medical conditions?(Required)
Does the patient take any medications (including inhalers or vitamins)?(Required)
Has the patient had any serious injuries (including a head injury)?(Required)
Does the patient have a birth or heart defect?(Required)
Has the patient ever been hospitalized overnight?(Required)
Has the patient had any surgery in the past?(Required)
Does the patient have any problems with sleeping and/or snoring?(Required)
Has the patient had a dental cleaning within the past 6-12 months?(Required)
MM slash DD slash YYYY
Does anyone smoke in the home?(Required)
Does the patient smoke, use e- cigarettes, or chew tobacco?(Required)
Does the patient get 60 min of exercise at least 3 times a week?(Required)
Are you concerned with the amount of time your child spends on social media, T.V., video games, computer, or phone?(Required)
Any other concerns about your child’s health or weight?(Required)

Patient History of the Following:

Anemia/Blood disorders(Required)
Asthma(Required)
Autism(Required)
COVID 19(Required)
Cancer/Leukemia(Required)
Diabetes/ Endocrine/ Gland Disease /Autoimmune(Required)
Digestive issues/Diarrhea/Constipation(Required)
Headaches/Migraines(Required)
Learning/Developmental Issues(Required)
Seasonal Allergies(Required)
Heart murmur(Required)
Skin problems (eczema, acne, etc.)(Required)
Seizures(Required)
Overweight or Obesity(Required)

Family History - Please Note Relationship to Patient

Anemia/blood disorders(Required)
ADD/ADHD(Required)
Asthma(Required)
Cancer/Leukemia(Required)
Diabetes/ Endocrine/ Gland Disease /Autoimmune(Required)
Headaches/ Migraines(Required)
Overweight/ Obesity(Required)
Skin problem (acne, eczema, etc.)(Required)
Mental Health Issues(Required)
Seizures(Required)
Heart Disease(Required)
Hypertension(Required)
Substance Use(Required)
Tobacco Use(Required)

Allergies

Any foods (including lactose intolerance)?(Required)
Any medications? (including over the counter or antibiotics)(Required)
Does the patient have an Epi-Pen (or similar prescription) at home/school?(Required)

Behavioral Health

Has the patient ever had or is currently receiving counseling services(Required)
With CFA?(Required)
Are you interested in receiving information about mental health counseling for your child?(Required)
Has the patient ever had any of the following:
Family changes(Required)
School issues(Required)
Social/peer stresses(Required)
Anxiety/Panic Attacks(Required)
Learning Disabilities(Required)
Anger issues(Required)
ADHD/Attention issues(Required)
Depression(Required)
Truancy/School avoidance
Recent loss/crisis(Required)
By signing below, I understand and acknowledge I have read and understand this consent:(Required)
RELEASE OF INFORMATION AND PAYMENT AUTHORIZATION(Required)
CONSENT AND ACKNOWLEDGEMENT OF PRIVACY PRACTICES(Required)
AUTHORIZATION FOR EXCHANGE OF HEALTH AND EDUCATION INFORMATION
I also certify that the health information provided is accurate to the best of my knowledge and understand that incorrect information can be dangerous to the patient’s health. I will notify the Community Bridge Clinic of any changes to medical information. By signing below, I understand that this authorization is valid until I revoke this authorization. I understand I may revoke this authorization at any time by submitting written notice of the withdrawal of my consent.
MM slash DD slash YYYY
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