Get the free Child Intake Form - Village Health Clinic
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DR. B. SLAVIC AND DR. T. DONG VILLAGE HEALTH CLINIC Naturopathic Medical & Midwifery Care CHILD×ADOLESCENT HISTORY (CONFIDENTIAL: All information in this form remains confidential and will be released
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How to fill out child intake form
How to fill out the child intake form:
01
Begin by gathering all the necessary information about the child, such as their full name, date of birth, and contact information.
02
Fill in the sections regarding the child's medical history, including any known allergies, current medications, and previous illnesses or surgeries.
03
Provide details about the child's immunization records, including the dates and types of vaccines received.
04
Answer questions related to the child's dietary restrictions, if any, and provide information about any preferred or prohibited foods.
05
Complete the emergency contact section, ensuring that accurate contact information is provided for at least two individuals who can be reached in case of an emergency.
06
Review the form for any missing or incomplete information and make sure to include any additional notes or special instructions if required.
07
Sign and date the form to confirm that all the information provided is accurate and complete.
Who needs the child intake form:
01
Parents or guardians who are enrolling their child in a childcare center or program.
02
Schools or educational institutions that require this form for new students.
03
Daycare providers, babysitters, or nannies who need to have detailed information about the child in their care.
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What is child intake form?
Child intake form is a document used to gather important information about a child entering a program or facility.
Who is required to file child intake form?
Parents or legal guardians are typically required to file the child intake form for their child.
How to fill out child intake form?
To fill out the child intake form, parents or legal guardians must provide accurate information about the child's personal details, medical history, and emergency contacts.
What is the purpose of child intake form?
The purpose of the child intake form is to ensure that program or facility staff have necessary information to care for the child properly and respond to any emergencies.
What information must be reported on child intake form?
Information such as the child's name, date of birth, medical conditions, allergies, medications, and emergency contacts must be reported on the child intake form.
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