3034238836
5150 Allison St Southwest Temp Bldg #4, Arvada, CO 80002
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New Patient Registration

CARIN’ CLINIC

A Pediatric Clinic That
Offers Affordable Health Care Services

Get in touch with our nurse practitioner today to learn more!

☎ 303-423-8836☎ 303-423-8836

New Patient Registration

Thank you for choosing Carin' Clinic, we look forward to caring for your child!

Please fill out the following forms, you will need to hit "submit" for each form, for a total of 4 forms. At the bottom of the page, the last link will take you to the pre-registration page of our electronic health record, please fill it out with your child's name and information.

After we receive all the forms, we will be happy to schedule an appointment for your child.

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Consent for Treatment

I understand that CARIN’ CLINIC may not be able to fulfill all the health needs that my child may have. If s/he requires services that CARIN’ CLINIC cannot provide, appropriate referrals will be made. I authorize CARIN’ CLINIC staff to provide care for my child. This care/service may include:

Age appropriate well-child exams consisting of a comprehensive health history, complete physical assessment, screening procedures, and anticipatory guidance.
Immunizations
Diagnosis and treatment of acute illness and injury
Management and monitoring of stable chronic conditions
Basic laboratory services on site
Ability to prescribe or dispense medications, in accordance with medical and pharmacy practice acts
Patient health education and anticipatory guidance for students and parents
Mental health services

Services are provided by certified pediatric nurse practitioners. All volunteers (nurses, doctors, staff) are covered by the Volunteer Service Act, CO Revised Statute 13-21-115.5. CARIN’ CLINIC does not provide the following services: x-rays, hospitalization, emergency care for life threatening conditions, long-term treatment of mental health problems, or treatment of complex medical or psychiatric conditions.

I authorize the release of written and verbal information pertinent to my son/daughter’s medical records to other health care providers as designated by me whenever necessary for my child’s care. This includes release of medication/prescription history from pharmacies and other health care providers.

I authorize the release of written and verbal information pertinent to my son/daughter’s health care between my child’s school counseling and health staff, and CARIN’ CLINIC, whenever necessary and appropriate for his/her care. I further give consent to CARIN’ CLINIC staff to examine my son/daughter’s school records for information that is necessary and appropriate to assist the staff in helping my child.

I authorize CARIN’ CLINIC to release information regarding treatment to third party users, such as Medicaid or others, for the purpose of billing and for any reason in accordance with acceptable medical practice pursuant to the law.

It is my responsibility as the parent to notify the clinic about changes in guardianship. I have read and completed this consent form to the best of my ability. I understand that I may call CARIN’ CLINIC with any questions that I may have.

Child’s name:	Please enter information...
Date of Birth:	YYYY-MM-DD
Name of Parent/Guardian:	Please enter information...
XX Signature:	Please enter information...
Date:	YYYY-MM-DD

I have read Notice of Privacy Practices on website and know that I can request a copy at the clinic:

XX Signature:	Please enter information...
Date:	YYYY-MM-DD

Typing you name is the same as your signature.

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Vaccines for Children Program (VFC)

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Patient Eligibility Screening Record

Vaccines for Children Program (VFC)

Carin’ Clinic

5150 Allison Street, Arvada, CO 80002

My child qualifies for vaccines through the VFC program because he or she:

Mi hijo califica para vacunas a través del programa VFC porque:

Please check...

Has Medicaid
Tiene la Medicaid

Please check...

Does not currently have health insurance

No tiene seguro médico

Please check...

Is American Indian or Alaskan native

Please check...

Has CHP+ or private insurance

Tiene CHP+ o seguro privado

Patient name Nombre del paciente	Please enter information...
Date of Birth Fecha de nacimiento	YYYY-MM-DD
Signature of Parent/Guardian Firma del Madre/Padre	Please enter information...
Date Fecha de hoy	YYYY-MM-DD

A record must be kept in the healthcare provider’s office that reflects the status of all children 18 years of age or younger who receive immunizations through the VFC program. The record may be completed by the parent, guardian, individual of record, or by the healthcare provider. This same record may be used for all subsequent visits as long as the child’s eligibility status has not changed. While verification of responses is not required, it is necessary to retain this record for each child receiving vaccines.

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Financial Review Form

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Carin’ Clinic

Financial Review Form

Date: Fecha:

YYYY-MM-DD

Patient Name:

Nombre del hijo

Please enter information...

Parent’s Name(s):

Nombre de Padre/Madre

Please enter information...

Marital Status:

Estado civil:

Please check... Married

Casado

Please check... Single

Solo

Please check... Divorced

Divorciado

Please check... Widowed

Viudo

Total Number of Persons Living in the Household:

Total número de personas que viven en el hogarPlease enter information...

Are you currently employed:

Es usted empleado actualmente:

Please check... Yes

Sí

Please check... No

Unemployed Since:

Desempleados Desde:

Please enter information...

Current Pay: $
Pago actual

Please enter information...

every:

cada:

Please check... Week

semana

Please check... Bi-Weekly

dos semanas

Please check... Month

mes

Please check... Year

año

Spouse employed?

Su esposo empleado?

Please check... Yes

Please check... No

Unemployed Since:

Desempleados Desde:

Please enter information...

Spouse’s Current Pay: $

Actual paga de esposo:

Please enter information...

every
cada:

Please check... Week

semana

Please check... Bi-Weekly

dos semanas

Please check... Month

mes

Please check... Year

año

Living Situation:

Situación de la vida:

Please check... Homeless

Sin hogar

Please check... Own

Casa

Please check... Home
Propia

Please check... Rent

Alquile

Other:

otros:

Please enter information...

By signing below, you state that the information presented is true and accurate to the best of your knowledge. Also, you will notify Carin’ Clinic if significant changes occur in your household income and/or living situation.

Al firmar abajo, estado que la información presentada es verdadera y exacta a lo mejor de su conocimiento. Asimismo, le notificará clínica Carin' producirse cambios significativos en su ingreso o situación de vida.

Parent’s Signature:

Firma del padre

Please enter information...

For Carin’ Clinic Staff

Proof of Income Presented:

Please check... Yes

Please check... No

Sliding Scale Category:

Please enter information...

Medicaid #

Please enter information...

Staff Initials:

Please enter information...

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Acknowledgement of Receipt of Notice of Privacy Practices

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Acknowledgement of Receipt of Notice of Privacy Practices

Carin’ Clinic 5150 Allison Street

Arvada, CO 80002

Privacy Officer: Edwina Quintana 303-423-8836

I hereby acknowledge that I have access to a copy of this medical practice's Notice of Privacy Practices via their website. I further acknowledge that a copy of the current notice will be posted in the reception area, and that a copy of any amended Notice of Privacy Practices will be available at each appointment.

Name of Child:

Please enter information...

Address:	Please enter information...
Telephone:	Please enter information...

Print Name of Parent/Guardian:

Please enter information...

Signature of Parent/Guardian:

Please enter information...

Date:

YYYY-MM-DD

***PLEASE LIST ANY OTHER PARTIES WHO CAN HAVE ACCESS TO YOUR CHILD’S HEALTH INFORMATION AND PERMISSION TO BRING YOUR CHILD TO THE CLINIC FOR TREATMENT***:

(This includes step-parents, grandparents and any care takers who can have access to this patient’s records, and who has permission to bring child to clinic):

Name:

Please enter information...

Relationship:

Please enter information...

Name:

Please enter information...

Relationship:

Please enter information...