Registration


Adult Health Assessment



Subjective Section


Please note that this form is not for any dental examinations.

Family History(FHX)


If yes, please state who in your family and state alive or deceased.


 Preventative Care Assessment



Females Only : OB& Pregnancy History



Males Only


Completion of PreRegistration for services provided by Portable Clinical Care staff does not replace your Primary Care Provider.

Child Consent PreRegistration form



Subjective Section



Family History(FHX)


If yes, please state who in your family and state alive or deceased.

What’s your child’s eating habits:

Completion of PreRegistration for services provided by Portable Clinical Care staff does not replace your Primary Care Provider.

Our Well Child exam includes the following in compliance with state requirements:
Physical assessment, urinalysis, diabetic screening (glucose/HbA1c), cholesterol (if child falls over 85% of weight), nutrition assessment, behavioral assessment, sports physical (if needed), obesity screening (BMI), high blood pressure screening, hearing screening, and vision screening. Parent/Guardian signing this form will receive a post evaluation sheet with information regarding the results/outcomes and contact information for the providers if you have provided an email address.

OUR COMMITMENT:
ProHealth is a federally qualified health center. All information is kept confidential in accordance with HIPPA rules and regulations.

You understand that by submitting this form you are consenting for the child named above to receive preventative services listed above offered by Jan Zwarts Valley Portable Healthcare. Your insurance will be billed for this physical exam. With the increasing amounts of annual deductibles and co-payment on commercial insurance, we will bill you for the difference between what your insurance company allows and what they actually pay. If you have selected discount, this amount can be discounted including Co-pay fees. If the child has no insurance, all fees will be waived. If you forgot or did not know that your child is insured, we will contact you for the information. This physical exam will count as your child’s yearly exam. Any abnormalities will be communicated to the parent that completed the form.

*Your insurance will be billed for this well child exam. These exams are the same as an annual visit to a primary provider of Medical, Behavioral, Nutritionist, Dentist, or Optometrist. Please be aware that TennCare, Private/Commercial insurances and CoverKids will pay for only one of each of these exams per year. Your child can receive their sports physical from ProHealth Community Health Center or their primary care doctor.