Obtain the following information from health care providers and state registries for the below named child/pregnant woman:
• medical and dental records (including follow-up care with specialists)
• lead and hemoglobin test results
• immunization records
• developmental screening results
• prenatal and postpartum documentation for pregnant women enrolled in EHS
The above information may be either electronic, written or verbal and will be released to:
Champlain Valley Head Start
Health Coordinator, Special Needs Coordinator,
Nurse Consultant or Tooth Tutor
255 South Champlain St., Suite 10
Burlington, VT 05401
(802) 651-4180 X215
I also consent to:
• Share and discuss results of my child’s Head Start screenings (vision, hearing, growth, oral health, and developmental) and health records with my child’s health care providers and/or state registries or CVHS collaborative partners in order to provide/support services for my child/family.
• Share my child’s growth assessment, enrollment and oral health status with WIC and its Public Health Dental Hygienists.
• If my child is transitioning to public school: share my child’s oral health status with the public school Tooth Tutor.
I acknowledge that:
• I may revoke this consent at any time (by contacting CVHS at the address or telephone number above) except to the extent that action has been taken in reliance on it before I revoked it.
• This consent will expire on December 31, 2024.
