Employee Visit

July 6, 2020 Nurse Line Uncategorized

Please complete the information below:

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
Office | School Address
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

Employee Visit

Name(s) of Students

Office | School Address

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

Employee Visit

Name(s) of Students

Office | School Address

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