Bourbon County School Based Health

School Year 2026 - 2027

Consent for Services (Adult)

Note: If you begin the form and need to finish later, click "Finish Later" and your progress will be saved. A link to resume your form will be emailed to you. It is valid for 24 Hours.

Information

School

First Name   Middle Name   Last Name
Gender   SSN Birthdate

Nickname
Race Ethnicity

Address City Zip Code
Contact Phone Work Phone Email
Preferred Communication

Emergency Contact Information

Primary Contact
Cell Phone Home Phone Work Phone
Primary Care Provider Pharmacy
Do you want a copy of this visit sent to your doctor? Yes No

Insurance Information

This information is REQUIRED for the student's health record to be complete but will ONLY be billed if services are provided by the SHS Provider. School nurse visits are not billed to insurance.
Do you have insurance? Yes No
Primary Insurance ID # Group #
Secondary Insurance ID # Group #

Insurance Policy Holder Information

Name Gender Phone Birthdate

SSN Address City State Zip Code

Medical History

Allergies (Please list ALL allergies including medications, vaccines, food or other)

Current Medication(s)
You will be asked to complete a separate Medication Consent form if you desire the School Nurse to administer this medication in the School.

Medication Name	Dosage	Directions

Hospitalization(s)

Reason for Hospitalization	Date of Hospitalization	Facility Where Hospitalized

Surgeries

Type of Surgery	Date of Procedure	Facility Where Procedure Was Performed

Has the Student ever been treated for any of the following:

Other

Family Medical History

Does any of the Student's family members have any of the following conditions? (No is selected by default)

Condition	No or Relation	Relative (Sibling, Parent, Grandparent)	Age
Heart Attack
High Blood Pressure
Congestive Heart Failure
Rheumatic Heart Disease
Congenital Heart Disease
Breast Cancer
Colon Cancer
Leukemia
Melanoma (Skin Cancer)
Ovarian Cancer
Pancreatic Cancer
Other Cancer
Colitis
Crohn's Disease
Colon Polyps
Hepatitis
Stomach Ulcer
Kidney Disease
Stroke
Asthma
Migraine
Seizures
Diabetes
Goiter
Bleeding Tendency
Suicide
Mental Illness
Tuberculosis
Drug or Alcohol Abuse
Other

Other Information

Do you smoke?	Yes No
Packs Per Day?		Number of Years?
Do you drink alcohol?	Yes No
Drinks Per Day?		Number of Years?

Assignment of Benefits / Consent for Treatment

I consent to the customary tests, procedures that may be deemed necessary for treatment of my child’s condition by members of the Medical Staff of Sterling Health Solutions, Inc. Center. Consent is hereby given for such visits to the school nursing office for the purposes of examination, treatment, and procedures rendered by a qualified Nurse Practitioner. I authorize the release of any medical or other information necessary to process this claim. I also request payment of government benefits to the party who accepts assignment. I authorize payment of medical benefits to the supplier for services provided by Sterling Health Care, Inc. Center. I understand that I may be billed separately for services provided by clinic providers for treatment related services. I hereby authorize payment directly to the professional providing these services which would otherwise be payable to me.
*Services performed by the school nurse are not billed.

Authorize for Release of Medical Information

I hereby authorize the release of medical information as necessary for settlement of this claim. Unless otherwise indicated, this authorization extends to such psychiatric, alcohol or drug abuse, and HIV related diagnosis information, if any, as may be contained in the clinic records. I understand that I have the authority to release the above reference medical records, as well as release of records to my child’s primary care provider. Further, I release Sterling Health Care, Inc. Center and any related corporations or affiliates from any liability resulting from the release of these medical records and agree to identify and hold them harmless from any such liability. This constitutes permission to release medical information regarding sexually transmitted disease, if applicable, to Third Party Payor pursuant to KRS 214.420.

I have read the above and understand that items above as it applies to me. I verify I have received a Notice of Privacy Practices (45 CFR 164.520 (2) (ii) and Bill of Rights.

Patient Signature

(Use mouse or touchscreen)

Clear Signature

Name Date Signed

Phone
Patient Portal Email Address

Note: IF Patient is unable to sign above or if an authorized person gives verbal consent, two witnesses are required.

Witness #1

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Clear Signature

Name Date Signed

Phone
Address

Witness #2

(Use mouse or touchscreen)

Clear Signature

Name Date Signed

Phone
Address