Get Tb Test Request Form

Any amount not covered by my insurer will become my financial responsibility. Parent/Guardian signature Today s Date Insurance Provider Name Policy Number Please contact Nedra Starling if you have questions - 216 444-3938 or starlin ccf.org H MY WORD WP DATA FILES ST MARTIN TB Test Request Form.wpd. TB TEST PERMIT The Cleveland Clinic Career Experience Shadowing Program TB Test Permit Form St* Martin de Porres High School Corporate Work Study Program Name Date SS Birthdate School Grade Requested by Cleveland Clinic Education Partnership Programs Office of Civic Education Initiatives CCF Contact Nedra A. Starling Coordinator 216 444-3938 B24933 Student Instructions 1 Print requested information above and your name on the line below for Student Name. 2 Have your parent/guardian sign and date the form below on the appropriate lines. 3 Arrive promptly at the assigned time location you are provided to have your TB test placed* 4 Note the return date to have your TB test read* You must return to have your TB test read at the designated time or your test will not be valid and you will not be able to start your assignment. PARENT/GUARDIAN PERMISSION FORM for tuberculosis TB. I also give my permission for the above named student to receive the Hepatitis B vaccine if this vaccine is requested by the student. I understand that any necessary follow up treatment s due to positive readings will be the responsibility of the student and his/her parent s / guardian s and not that of The Cleveland Clinic nor the Partnership Office. If my son/daughter/ minor dependent tests positive I agree to provide written documentation from their health care provider including information on prescribed medication treatment s and readings of any additional x-rays stating that they are free from communicable disease before they may start their rotation at Cleveland Clinic* Further if the student requests the Hepatitis B vaccine my insurance provider will be billed for the charges. TB TEST PERMIT The Cleveland Clinic Career Experience Shadowing Program TB Test Permit Form St* Martin de Porres High School Corporate Work Study Program Name Date SS Birthdate School Grade Requested by Cleveland Clinic Education Partnership Programs Office of Civic Education Initiatives CCF Contact Nedra A. Starling Coordinator 216 444-3938 B24933 Student Instructions 1 Print requested information above and your name on the line below for Student Name. Starling Coordinator 216 444-3938 B24933 Student Instructions 1 Print requested information above and your name on the line below for Student Name. 2 Have your parent/guardian sign and date the form below on the appropriate lines. 3 Arrive promptly at the assigned time location you are provided to have your TB test placed* 4 Note the return date to have your TB test read* You must return to have your TB test read at the designated time or your test will not be valid and you will not be able to start your assignment. 2 Have your parent/guardian sign and date the form below on the appropriate lines. 3 Arrive promptly at the assigned time location you are provided to have your TB test placed* 4 Note the return date to have your TB test read* You must return to have your TB test read at the designated time or your test will not be valid and you will not be able to start your assignment. PARENT/GUARDIAN PERMISSION FORM for tuberculosis TB. I also give my permission for the above named student to receive the Hepatitis B vaccine if this vaccine is requested by the student.