Nurse Line

Select the Appointment Type*

Appointment Date*

Appointment Time*

Do you have health insurance?*

File Upload | Front Side | Health Insurance Card

Front Side

File Upload | Back Side | Health Insurance Card

Back Side

Name(s) of Students

Student Information

Please the names of all the students that will receive TB Testing. Click the + sign at the end of the row.

Student First Name	Student Last Name	Date of Birth (MM/DD/YYYY)	Student Phone Number

Do you have a Minnesota ID/Driver's License?*

File Upload | Front Side | Minnesota ID/Driver's License

Front Side

File Upload | Back Side | Minnesota ID/Driver's License

Back Side

Address where the screening (s) will be performed.

School Name*

County where School is Located:*

School Address*

Street Address City State / Province / Region ZIP / Postal Code Country

Service Agreement*

This form constitutes a Service Agreement between above named office/school and Brij Health to provide on-site tuberculosis screening for students, parents, teachers/faculty and other staff members.
School agrees to provide a space, tables, and chairs to accommodate Brij Health clinical staff providing screening/immunizations.
Brij Health shall maintain the security and privacy of identifiable health information as required by law. Brij Health will comply with all applicable laws and regulations.
Brij Health will provide qualified, licensed personnel, flu clinic administrative support staff where required, immunization supplies and consent forms.
Brij Health require that the school guarantees, assures or otherwise commits to a minimum participation.

Signature