Parent/Guardian Telemedicine Appointment Request

Pasco County Schools, in collaboration with Premier Community Health (hereinafter, Premier), is providing your child an opportunity to participate in a Telemedicine visit with a Premier medical provider. In order for Pasco County Schools to assist with and initiate this opportunity, we need your parental consent in accordance with the Parents’ Bill of Rights (Ch. 1014, F.S.) and FERPA (20 U.S.C. 1232g). If consent is provided, Premier will be reaching out to you to schedule the visit and obtain the necessary insurance and medical information needed, along with their own consent to provide services. Pasco County Schools will not be able to view any of the information that you provide to Premier. The consent, below, allows Pasco County Schools to initiate this referral opportunity and to share the information in this consent form with Premier.

Parent/Guardian Name Parent/Guardian Name First Last
Parent/Guardian Date of Birth Parent/Guardian Date of Birth / MM / DD YYYY
Parent/Guardian Email
Parent/Guardian Cell Phone Number (Must be Cell Phone) Parent/Guardian Cell Phone Number (Must be Cell Phone) - ### - ### ####
Student Name Student Name First Last
Student ID#
Student Date of Birth Student Date of Birth / MM / DD YYYY
Address Address
Street Address Address Line 2 City State / Province / Region Postal / Zip Code Country
What school does your child attend?
Reason for requesting a Telemedicine visit for your child? (Select all that apply)

Reason for requesting a Telemedicine visit for your child? (Select all that apply) Allergies Asthma Bronchitis Cellulitis Cold and Flu Sore Throat Cough Conjunctivitis Diarrhea Vomiting Fever Ear Pain Head Lice Headache Infections Insect Bites Minor Cuts and burns Nasal Congestion Rashes Respiratory Infections
Please list any other symptoms or other pertinent information that you feel is needed.
List any allergies your child has
Do you have a Preferred Pharmacy?

Do you have a Preferred Pharmacy? Yes No
Name of Preferred Pharmacy
Address of Preferred Pharmacy Address of Preferred Pharmacy
Street Address Address Line 2 City State / Province / Region Postal / Zip Code Country
Phone Number of Preferred Pharmacy Phone Number of Preferred Pharmacy - ### - ### ####
Return Visit to Telemedicine: Premier has my child's completed consent form and I agree to have a member of the school health team schedule a Telemedicine Visit.

Return Visit to Telemedicine: Premier has my child's completed consent form and I agree to have a member of the school health team schedule a Telemedicine Visit. Yes No
I consent to having my child participate in a Telemedicine visit and I as the parent/guardian choose to participate in the following manner:

I consent to having my child participate in a Telemedicine visit and I as the parent/guardian choose to participate in the following manner: I as the parent/guardian will attend the visit utilizing videoconferencing technology I as the parent/guardian will be physically present during the telemedicine visit I as the parent/guardian will not attend physically or virtually
By my electronic signature below, I am authenticating that I am the child’s parent/guardian, with the right to execute this authorization in accordance with the Parents’ Bill of Rights, and that I understand, agree, and authorize Pasco County Schools to initiate a referral for the above-referenced services and to share my contact information with Premier for the purposes of arranging a telemedicine visit. Furthermore, I understand and agree to both a medical provider from Premier and a Pasco County School Health Team Member being present. I understand that this consent and authorization is continuous in nature and will permit the consented referrals and information disclosure for one (1) year from the date of my signature, or until I revoke such consent in writing to the school nurse of my child’s school, whichever occurs first. I understand that all confidentiality protections afforded by law or regulation will apply to my child's care and that any releases of information arising from this care are subject to the same laws and regulations as would apply to in-person care.

Draw or Type

I understand this is a legal representation of my signature. Clear

Full Name

I understand this is a legal representation of my signature.