IMMUNIZATION RECORD. I have provided the childcare operation with a copy of my child’s most current immunization record. ADMISSION REQUIREMENT: If your child does not attend pre-kindergarten or school away from the child-care operation, one of the following must be represented when your child is admitted to the child-care operation or within one week of admission. Please check only one option: 1. HEALTH-CARE PROFESSIONAL’S STATEMENT: I have examined the above named child within the past year and find that he / she is able to take part in the day care program. Health Care Professional’s Signature Date 2. A signed and dated copy of a health care professional’s statement is attached.
IMMUNIZATION RECORD. Physician Progress Notes Operative Report History and Physical Examination Probation Records Adoption Records Lab, Radiological Reports Physician Orders Medication Records Consultation Records Other: This information is needed for the following purpose(s): Continued Care Other: This authorization is good for one (1) year from the date signed at which it will be null and void. This consent is subject to revocation by the undersigned at any time except to the extent that action has been taken in reliance thereon. I understand revocation must be in writing. Participant DOB: Date Parent/Sponsor (not necessary if Participant is 18 or over) Date AUTHORIZATION FOR OPI TO RELEASE/EXCHANGE INFORMATION I, hereby authorize the Optimum Performance Institute to disclose OPI treatment information and records on to: (Participant Name) PARENT(S)/GUARDIAN/FINANCIAL SPONSOR: OTHER: Name(s): Phone E-mail: Name(s): Phone: E-mail: REFERRAL SOURCE: OTHER: Name: Phone: E-mail: Name(s): Phone: E-mail: OTHER: OTHER: Name: Phone: E-mail: Name(s): Phone: E-mail: The disclosure of this information is for the following purpose: To provide the greatest quality of care by working collaboratively with those who could be of assistance to the participant. This may include weekly updates as to the status and progress of the participant. Information to be released may include (please check): Treatment plan and goals Diagnosis Discharge Planning Progress updates Medication changes Drug/Alcohol test results Behavioral interventions ___ Other _ The transmission of this information my be telephone, mail and or email. OPI will take all precaution regarding electronic transmissions, however, E-mail transmission cannot be guaranteed to be secure or error-free as information could be intercepted, corrupted, lost, destroyed, arrive late or incomplete, or contain viruses. Therefore OPI does not accept liability for email transmissions once it leaves our systems. Limitations of information to be discussed are as follows: Information will not be released by OPI if it is believed that to release it would be harmful or detrimental to the participant’s treatment. I understand that I have a right to receive a copy of this authorization. I understand that any cancellation or modification of this authorization must be in writing and I have a right to revoke it at any time. This authorization shall remain valid for the entire time of receiving treatment at OPI and up to 30 days after discharge. Participant Nam...
IMMUNIZATION RECORD. Please attach a photocopy of your child’s Immunization Record(s) Please make sure that 1) the record also contains your child’s name and birth date.
