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University Parkway Fort Bonifacio, 1634 Taguig Metro Manila, Philippines Mailing Address: P.O. Box 1526 MCPO 1255 Makati City, Philippines Tel +632 840 8400 Fax +632 840.8405
__________________________________
The information on this form will be treated as confidential and will only be shared with school personnel on a need-to-know basis.
Preferred Name: Date of Birth: _ ____/__ ___/__ ___ Both Parents Father Nationality: Mother Guardian
Gender: M / F
Home Address:
Home Address:
Home Phone #: Cell Phone #: Direct office line #: Office Phone #: Company Name: Languages Spoken:
Home Phone #: Cell Phone #: Direct office line #: Office Phone #: Company Name: Languages Spoken:
NOTE: Please notify the Admission Office of any changes in phone numbers or contact persons
ISM Health Clinic Form Page 1 of 4
Does the student need to take any medication/s during school hours?
(If so, a letter from the Medical Doctor must be kept on file in the School Health Clinic and the medication/s kept in the Clinic to be dispensed by the School doctor or nurse.)
Any other health condition that the school should be aware of, e.g. diabetes, epilepsy, etc.: Does the child have any present illness: No Yes
Yes
Age
Asthma Heart Disorder Urinary Disorder Epilepsy Scoliosis Other Illness
No
Yes
Age
No
Yes No
Normal
Abnormal
Page 2 of 4
Normal
Abnormal
Comments:
No
Yes
Date
The tests / immunizations below are mandatory according to school policy and must be current before a student is admitted to ISM.
DATE
DATE
DATE
DATE
DATE
Please attach a copy of your childs immunization record or complete the schedule including dates:
TYPE
DPT / DT Tetanus Polio Measles Mumps Rubella Typhoid / injection / oral every 3 years Tetanus-booster every 10 years Hepatitis A Hepatitis B Other vaccination/s
DATE
DATE
DATE
DATE
DATE
Page 3 of 4
LEGEND: C M X RF U J P AM TF S W -
caries free caries missing tooth for extraction root fragment unerrupted tooth jacket crown pontic amalgam filling temporary filling sealant composite
AUTHORIZATION
I give consent for my child to receive the following: NO * 1. Minor first aid (at the clinic) YES * 2. Emergency care (at the clinic) YES NO NO * 3. Emergency care at Makati Medical Emergency Room YES * 4. Oral non-prescription medication YES NO * NOTE: If NO to 1, 2, and/or 3 above, the student may not enter school until alternative emergency care instructions are on file with the School Health Clinic . I hereby authorize the ISM Dentist to give the following dental treatment to my child, as the need arises: 1. Annual oral examination YES NO NO 2. Emergency dental treatment YES Permission is hereby given for emergency measures to be initiated in case of accident or sudden illness with the understanding that I will be notified as soon as possible. I certify that all information given on this card is complete and correct. I acknowledge that it is my responsibility to inform the ISM School Health Clinic of any changes in my childs health, physical condition or medical needs. Parents Signature: Date:
ISM Health Clinic Form Page 4 of 4