Forms & Information
What to do before your appointment
Don't waste time filling out forms when you get to the clinic - print them off and fill them out now! Many of the forms only need to be completed prior to your first clinic visit of the school year.
All forms are in .pdf format
Make sure your parent(s) have signed this out before you come to the clinic.
This needs to be completed just once during your high school career or if your insurance status changes.
Sign once a school year
Complete once a school year
Complete once a school year (just one side)
Vaccine Administration Consent
Make sure your parent(s) have signed this out before you come to the clinic so you can get your shots.
2013-2014 Sports Physical Forms
Minnesota State High School League required sports physical forms.
Sports Physicals are offered during the summer months by appointment and during the school year. MPS requires a sports physical every 3 years for students participating in school sports. Call your School Based Clinic to make an appointment
Notice of Privacy Practices: Updated 09/11
This notice describes how medical information about students may be used and disclosed and how get access to this information can be obtained.
School Based Clinic Brochure
Information on what the School Based Clinics have to offer.
School Based Clinic Pocket Brochure
A convenient pocket-sized brochure for students to learn what the School Based Clinics have to offer.
- Minneapolis School Based Clinic services are available to any student enrolled at a Minneapolis Public High School where the clinics are located.
- Students or parents will not be charged for any services students receive in the clinic. We may bill your insurance. If insurance does not cover the cost of service, you will not be billed.
- Interpreters available as needed.
- Parental consent forms are available at the clinics and are needed for all non-confidential services. If we have a signed Parent Consent Form on file, we will honor the parents' requests. If we have no consent form on file, the student will be able to receive confidential services under Minor Consent Law (MN Statute # sec 144.341-347). Confidential services include: pregnancy testing and counseling, contraceptive exams and prescriptions, sexually transmitted disease education, diagnosis and treatment, medical and mental health emergencies. In all cases, students are strongly encouraged to discuss confidential service issues with their parents or guardians.
- Patients can view their rights and responsibilties on the Patient Bill of Rights.
- North High School-Based Clinic is administered by NorthPoint Health & Wellness Center. Please call NorthPoint at (612) 302-4635 for more information.
- All other Minneapolis High School Based Clinics are administered by the Minneapolis Health Department (MHD). Please call (612) 673-5305 for more information or visit Clinic Locations.
Minneapolis School Based Clinics is a program of the Minneapolis Health Department.
Minneapolis Health Department
250 South 4th Street, Room 510
Minneapolis, MN 55415
If you need this material in an alternative format please call Minneapolis Health Department at (612) 673-2301 or email firstname.lastname@example.org
Deaf and hard-of-hearing persons may use a relay service to call 311 agents at (612) 673-3000. TTY users may call (612) 673-2157 or (612) 673-2626.
Attention: If you have any questions regarding this material please call Minneapolis Health Department at (612) 673-2301.
Hmong - Ceeb toom. Yog koj xav tau kev pab txhais cov xov no rau koj dawb, hu (612) 673-2800; Spanish - Atencion. Si desea recibir asistencia gratuita para traducir esta informacion, llama (612) 673-2700; Somali - Ogow. Haddii aad dooneyso in lagaa kaalmeeyo tarjamadda macluumaadkani oo lacag la' aan wac (612) 673-3500
Last updated Feb. 26, 2014