Primary Care Provider (Pcp) Authorization Form 2012-2013 - Jefferson County Public Schools Health Services
ADVERTISEMENT
1
2Jefferson County Public Schools Health Services
Primary Care Provider (PCP) Authorization: Other Health Conditions (Side One)
2012-2013 School Year
Student Name: __________________________Date of Birth: _________________School:
__________________________________
Oral/Nasal Suctioning (circle one)
DIAGNOSIS:
*All supplies and equipment are to be provided by the parent/guardian.
Sickle Cell Anemia
ADHD/ADD
Suctioning Instructions:
Cystic Fibrosis
Autism
Oral Suctioning
Nasal Suctioning
Long QT Syndrome
Ostomy Type: _______
Yanker/Soft tip catheter
Saline Instillation needed
Hemophilia
Spina Bifida
Other (Explain): _______________________________
Suctioning Frequency
Hypertension
Fainting Spells
Every _______ minutes
Every ______ hours
OTHER (SPECIFY): _____________________________
As needed based upon signs and symptoms as follows:
Choking/Continuous coughing/Gurgling
Upon student’s request
Latex Allergy
Yes
No
Other (Specify): ________________________
Urinary Catheterization
Urethral
Suprapubic
PRECAUTIONS AT SCHOOL: ____________________________
*All supplies and equipment are to be provided by the parent/guardian.
________________________________________________________
Times for procedure (Be Specific): ______ ______ ______ ______
Recommended position:
________________________________________________________
_______________________________________________________
RESTRICTIONS/EXCLUSIONS AT SCHOOL: ______________
If questions regarding catheterization times, may we contact the parent/guardian for
decision?
Yes
No
________________________________________________________
________________________________________________________
Can this student catheterize him or herself?
Yes ___Independently ___Adult Assistance
No
OTHER COMMENTS: ___________________________________
Check the typical characteristics of student’s urine:
Clear
Cloudy
________________________________________________________
Odor
Typically has blood in
Typical color and amount of output:
______________________________________________
Nutritional information is available at
* Please note: When any changes in the student’s typical characteristics are
or you may call 3186 for information.
observed, THE PARENT/GUARDIAN MUST BE NOTIFIED IMMEDIATELY.
Please complete both sides of this form. Form must be signed by
Initials/Date
Health Care Provider and Parent/Guardian.
Reviewed by Health Services
___________
Entered by Health Services
___________
School received/sent to Health Services ___________
ADVERTISEMENT
0 votes
Related Articles
Related forms
Primary Care Provider (pcp) Authorization Form: Respiratory Disorders - Jefferson County Public Schools Health Services
Business
Primary Care Provider (pcp) Authorization Form : G-tube/swallowing/feeding Disorders - Jefferson County Public Schools Health Services
Business
Authorization To Give Over The Counter Medication Form - Jefferson County Public Schools - 2012-2013
Business
Authorization To Give Prescription Medication Form - Jefferson County Public Schools - 2012-2013
Business
Form Fol-7 - Fayette County Public Schools Claim For Refund Of Overpayment Occupational License Tax Withheld For Schools - 2000
Financial
Preventative Health Care Examinations Permission Form - Jefferson County Public Schools (jcps) Health Services
Business
Related Categories
Parent category: Business