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  • Manatee County School Telehealth

    Please complete and sign this consent form so that your child can receive Telehealth care.
  • Patient/Student Information

  • Date Format: MM slash DD slash YYYY
  • Demographic Data

  • Insurance Information

  • Date Format: MM slash DD slash YYYY
  • Accepted file types: jpg, gif, png, pdf.
  • The above information is true to the best of knowledge. If I ever have any change in my health, I will inform my doctor
  • Date Format: MM slash DD slash YYYY
  • Patient/Student Medical History Survey