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

Mpls-School-based-clinics

Minneapolis School Based Clinics on Facebook Minneapolis School Based Clinics on Twitter Minneapolis School Based Clinics on YouTube
SBC on social media

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.

2014-2015 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.

School Based Clinic Pocket Brochure
A convenient pocket-sized brochure for students to learn what the School Based Clinics have to offer.

Policies

Minneapolis School Based Clinics is a program of the Minneapolis Health Department.

MHD_Horiz

 

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
health.familysupport@minneapolismn.gov
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 May 14, 2014