Consent & Registration Form

Dear Parent/Guardian: Call us if you have any questions regarding this form.
Contact 615-852-7088

Thank you for “registering” and giving your “consent” online! It is very important that you complete every question in the form below. After completing the form, you will be sent a confirmation email. There will be additional instructions in that email for you to complete.

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New Horizons Solutions, Inc. (NHS) will be at your child’s Community Center to perform health screenings that will include medical, vision, hearing, developmental/behavioral, and dental. If the examination results indicate your child is in need of closer attention in any of these areas, a referral will be made to appropriate medical personnel based on findings. NHS will NOT be treating your child. If you do not have a provider, one will be chosen for you by your Managed Care Organization.

These health screenings are being provided at the school and are done during school hours. If you are interested in your child having a health screening, please complete the following forms (including signing the consent) and return to the school as soon as possible. These services are also provided by your Primary Care Provider. If you are seeing your PCP, please continue to do so.

The screenings include the following:

  • A comprehensive history including developmental/behavioral screenings.
  • Vision and hearing screenings.
  • A complete head-to-toe physical exam (your child will be partially unclothed, but suitably draped during this exam – a staff member will be present).
  • Immunization review: Parents must give signed consent for release of immunization record (shot record) to be reviewed by New Horizons Solutions, Inc. staff. We will follow up with you if immunizations are needed.
  • The following lab (blood work) is collected from a finger stick and lab will be completed only: (a) at the ages shown below (b) when requested by parents/guardians (c) when medically necessary.
  1. Urine: Five year olds and 16 year olds and older
  2. Hematocrit /Hemoglobin (Iron): Five year olds and 13 year olds and older
  3. Total Cholesterol: Five year olds and older at risk
  4. Lead: Five year olds and younger at risk
  5. Glucose (Sugar): Children identified at risk

View our Privacy Policy here.

    Parent or Guardian Consent / Waiver Registration Form

    * Indicates Required Information

    Child's Registration Information

    Child's Full Name *:
    Child's Social Security Number * :
    Address :
    City :
    State : (ex. TN)
    Zip :
    Sex : FemaleMale
    Child's Date of Birth * : (mm-dd-yyyy)
    Name of the Child's School :
    Child's Grade :
    Section :
    Teacher's Name :
    Name of Child's Doctor or Clinic :

    Name of Insurance Carrier (Please select one): Tenn-Care SelectBlueCareCignaAmeriChoiceAmeriGroupJohn DeereUnited Health CommunityCCareInsurance

    Insurance Member ID :

    Medicad ID :

    Parent or Guardian's Consent Information

    Responsible Party's Full Name *:
    Parent/Guardian's Email @ Address * :
    Relationship to Child :
    Home Phone Number * : (ex. 615-123-4567)
    Work Phone Number :

    Cell Phone Number* :

    Primary Language Spoken At Home :

    In Case of Emergency, please provide the following:

    Full Name of Friend or RelativeNOT Living With You * :
    Relationship to Child * :
    Their Phone Number * :

    Parent / Guardian CONSENT and ACKNOWLEGMENT

    Do you want to be present during the exam? YesNo

    By checking the box, I am giving my consent. My child has permission to receive the annual physical exam conducted by New Horizons Solutions, Inc. I have been notified of NHS's privacy practices. I give permission for my child's screening results to be released to my Managed Care Organization (MCO), Health Department, the school system for treatment purposes, and my child's physician/primary care provider. I give my permission to release my child's immunization record (shot record) for review by New Horizons Solutions, Inc.™

    Please answer the question to make sure you are human.

    An UNCLOTHED EXAM is the same as in your doctor’s office and includes the following procedures:

    1. Listening to the heart and lungs; 2. Feeling and listening to the stomach; 3. Checking the back for scoliosis (curve of the spine); 4.Checking the femoral pulse (a heart beat located on the lower stomach and upper leg); 5. Examining the skin for problems such as rashes or infections; 6. Assessing stages of development through observation.

    A Pediatric or Family Practice Nurse will conduct the unclothed exam behind a privacy screen. During the unclothed exam, clothes will be lifted. The Provider will ask your child for their permission to complete each part of the exam. You are encouraged to be present during the entire exam.