Minneapolis
Health Department

Public Service Center
250 S. 4th. Street, Room 510
Minneapolis, MN 55415
health@minneapolismn.gov
(612) 673-2301

Directions & Parking for
Public Service Center

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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

Clinic Registration & Consent Form

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.

Data Privacy Acknowledgment

Sign once a school year

Personal Health History

Complete once a school year

Pediatric Symptom Checklist

Complete once a school year (just one side)

Other Forms

Vaccine Administration Consent
Make sure your parent(s) have signed this out before you come to the clinic so you can get your shots.

2016-2017 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

Sports Physical Welcome Letter

Youth Sports Physical Information Flyer

Sports Qualifying Physical History Form

Consent to Release Medical Information

 

Information

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.

Policies

  • 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 Logo

For reasonable accommodations or alternative formats please contact the Minneapolis Health Department at 612-673-2301 or health@minneapolismn.gov. People who are deaf or hard of hearing can use a relay service to call 311 at 612-673-3000. TTY users call 612-673-2157 or 612-673-2626.
Para asistencia 612-673-2700 - Rau kev pab 612-673-2800 - Hadii aad Caawimaad u baahantahay 612-673-3500.

 

 

Last updated Jun 30, 2016