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