Forms & information

School-based clinics forms for parents and students

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.

Clinic Registration & Consent Form

Clinic Registration & Consent Form - Spanish

Clinic Registration & Consent Form - Somali

Make sure your parent(s)/guardian(s) have filled 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.

Minor Registration & Consent Form

Minor Registration & Consent Form - Spanish

Data Privacy Acknowledgment

Data Privacy Acknowledgment - Spanish

Sign once per school year

Personal Health History

Personal Health History - Spanish

Personal Health History - Somali

Personal Health History - Oromo

Complete once per school year

Other forms

School Based Clinic COVID-19 Consent Form

Vaccine Administration Consent

Vaccine Administration Consent - Spanish

Make sure your parent(s)/guardian(s) have filled this out before you come to the clinic so you can get your shots.

Physical Examination Medical Eligibility Form

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

Mental Health Informed Consent Form

Mental Health Informed Consent Form - Spanish

Information

Notice of Privacy Practices

This notice describes how medical information about students may be used and disclosed and how access to this information can be obtained.

School-Based Clinics 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 are available as needed.
  • Clinic Registration & Consent Form 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 do not have a 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.
  • Clients can view their rights and responsibilities on the Client Bill of Rights .
  • North High School-Based Clinic is administered by NorthPoint Health & Wellness Center. Please call NorthPoint at (612) 543-2500 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.
 

Request accessible format

If you need help with this information, please email 311, or call 311 or 612-673-3000.

Please tell us what format you need. It will help us if you say what assistive technology you use.

Contact us

Minneapolis Health Department

Phone

612-673-2301

Address

Public Service Building
505 Fourth Ave. S., Room 520
Minneapolis, MN 55415