Medical Information Form

EMERGENCY CONTACTS

Student Name*

First Last

Date of Birth

Parent Name

First Last

Home Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Phone Number

Emergency Contact 1 (in addition to parents)*

First Last

To be contacted in the event of an emergency, if parent/guardian cannot be reached.

Phone Number

Emergency Contact 2 (in addition to parents)

First Last

To be contacted in the event of an emergency, if parent/guardian cannot be reached.

Phone Number

Medical History

Immunizations current?*

If no, please fill out a vaccine exception form.

Yes
No

Glasses

Yes
No

Contacts

Yes
No

Hearing problems

Yes
No

Orthodontics presently

Yes
No

Cold sores

Yes
No

If yes, please send your student with medication to treat as needed.

Skin problems

Yes
No

Scoliosis

Yes
No

Surgeries

Yes
No

Seizures

Yes
No

Depression

Yes
No

Anxiety

Yes
No

Anger management issues

Yes
No

Panic disorder/issues

Yes
No

Phobias

Yes
No

ADD/ADHD

Yes
No

Learning difficulties

Yes
No

Sleeping problems

Yes
No

Eating problems/disorders

Yes
No

History of /current professional counseling

Yes
No

Need for continued therapy

Yes
No

Diabetes

Yes
No

High blood pressure

Yes
No

Heart problems

Yes
No

Arthritis

Yes
No

Asthma

Yes
No

Restriction on physical activities

Yes
No

Is your student at increased risk for COVID-19?

Yes
No

If you answered YES to any of the above, please explain

KNOWN ALLERGIES: Please list any allergies and the allergic response:

Anything else you'd like us to know about your student's medical history?

Buxton School Over-the-Counter Medications

Please Indicate which topical or oral OTC medications you do NOT want administered to your child

Parent/guardian electronic signature*

Today's Date

CURRENT HEALTH INSURANCE INFORMATION

Student's name*

First Last

Health Insurance Company*

Policy number*

Subscriber’s name*

Subscriber’s birthdate*

Health Insurance Card*

Max. file size: 100 MB.

Please upload images/copies of your student's health insurance card - front & back. Thank you!

Health Insurance Card (back)*

Max. file size: 100 MB.

Prescription Card

Max. file size: 100 MB.

If your student's prescription insurance is different than their medical insurance, please include photos of the front & back of the prescription insurance card.

Prescription Card (back)

Max. file size: 100 MB.

Dental Insurance

Max. file size: 100 MB.

If your student has separate dental insurance, please include photos of the card, front & back.

Dental Insurance (back)

Max. file size: 100 MB.

Phone

This field is for validation purposes and should be left unchanged.