Authorization For Treatment - Beacon College
ose 2Dose 3MMDDYYMM-AND-Rubella (German Measles)YYTiter/DateDDYYMMTd (Tetanus/Diphtheria)DDYYMMDDYYTdap (Tetanus/Diphtheria/Pertussis)ORMM DD YYMM DDCopy of lab report must be attachedYYMMDDYYMMDDYYB. Immunizations recommended for good health:MumpsMMVaricella (Chicken Pox) 2 shots or date of illnessDose 1Dose 2DDHPVYYMMDDPolio (last dose)YYMMDDYYHepatitis ADate of IllnessDose 1Dose 2ORMMDDYYMMDDYYMMDDYYMMDDYYMMDDYYC. An official stamp from a doctor’s office, clinic, or health department AND an authorized signature must appear on thisform.Name of Public Health Clinic or Physician (facility stamp)Send or fax form as soon as possible to:Attention: Debra D. AllenBeacon College, Student Services105 East Main St. Leesburg, FL 34748-OR-Physician or Authorized SignatureEFax (800) 313-0339Phone (352) 638-9701DatePLEASE KEEP A COPY FOR YOUR RECORDS
Medical Action Plan & Local Medical Resource ListMerriam-Webster's Desk Dictionary defines transition as “passage from onestate or stage to another”. So whether you are entering college for the first timeor are a transfer or continuing student, you are experiencing importanttransitions in your life. You are transitioning to a new place, newresponsibilities, new challenges.To get started:The MAP must be completed by ALL students . Ifyou have chronic medical needs, the MAP will help you be better preparedto take responsibility for your health needs. Continuityof quality medical care is of primary importance to your success incollege. Local Medical Resources are provided for your reference on pages4-7. Please keep those pages for future reference.Now is the time to prepare yourself. Establish a routine that supports your besthealth. Keep a calendar to manage your responsibilities: going to class,mentoring, keeping appointments, taking medications as prescribed, eatinghealthy, studying, sleeping, exercising, socializing, etc. Get involved! There aremany workshops, student activities, clubs, and organizations to support yourpersonal wellness.If you have any questions or concerns or need assistance, please contact me.Sincerely,Debra D. Allen RN, MSN, FNPDirector of Student HealthStudent Services, Beacon College(352) 638-9701dallen@beaconcollege.edu
NAME:MEDICATIONPlanning for success means making the right choices for your health. Now that youare in college and living on your own, it is important that you plan ahead for success.Properly taking medications can make the critical difference between success andfailure. Know the name, purpose, side effects, restrictions, interaction precautions,how to take, and how to order and pay for your medications. Keep a calendar, planahead so you don’t run out! An interruption in taking medication can sometimes haveadverse effects. Take a minute and consider the following questions, answer to thebest of your ability. (check if applicable) I’m not taking any prescribed medications.How will you make sure you take your medication as prescribed? Take on my own Take when reminded by a parent Take with help of a pill organizer Take with Lab/Doctor AssistanceOtherHow will you make sure you keep a supply of medication to make sure you don’trun out? Local Pharmacy Mailed from Home Mailed direct from Pharmacy Own Transportation to Pharmacy College Transportation to PharmacyOtherHow will you pay for your medication? (Check all that apply, explain if needed) Parent Student Direct through Pharmacy or InsuranceWhat happens when you don’t take your medication? What happens when youdo?MedicationHow often toRefill?Next Date toRefill?Instructions for taking2
NAME:MEDICAL CAREPlan Ahead! Do your homework now and identify medical care professionals close toBeacon College. Schedule appointments in advance and have records forwarded. Ifusing college provided transportation, reserve your time in advance-remember this is afirst come first serve basis. Be sure to notify transportation and the doctor if you needto cancel or reschedule an appointment. You may still need to pay if you fail to keepan appointment or to cancel or reschedule with advance notice. It is especiallyimportant for students with chronic illnesses to establish a relationship with a localphysician who can monitor their care.Medical Care at HomeDoctor NameType of PracticeScheduledappointments/frequencyPhone NumberScheduledappointments/frequencyPhone NumberLocal Medical Care while at BeaconDoctor NameType of PracticeSignature:Date:3
LOCAL MEDICAL RESOURCE LISTPLEASE KEEP PAGES 4-7 FOR YOUR RECORDSThis information is provided as an example of medical service practitioners in the Leesburg area. Thislist does not represent an endorsement or recommendation by the college, its directors, officers oremployees, of any particular medical service provider or practitioner. Before seeking medical assistancebe sure to check with your insurance company. Students are responsible for arranging their ownmedical appointments and transportation. Limited transportation is available on a first come basisduring weekday business hours and is limited to necessary medically related issues; contact theTransportation Coordinator to schedule transportation. There may be a minimal fee and service may belimited to a 20 mile radius. Students and/or parents are responsible for payment of all medical expenses.Family PhysiciansPhysicians’ Referral(352) 323-1000Leesburg Family Medicine802 East Dixie Ave., Leesburg, FL 34748(352) 787-1324Dr. Rolando Menendez608-A South 9th St., Leesburg, FL 34748(352) 365-2221NCS Counseling and Development CenterDr. Nadine Vaughan101 East Maud St., Tavares, FL 32778(352) 253-9348Central Florida Psychological ConsultantsDr. W. Steven Saunders1114 W. Dixie Ave., Leesburg, FL 34748(352) 365-2243Leesburg Community Health Center225 N. 1st Street, Leesburg, FL 34748(352) 360-0490Lake Center of HopeDr. Ludy Ungson33057 Professional Drive, Suite 102Leesburg, FL 34788(352) 787-0081Lake County Health Department14 N. Eustis Street, Eustis, FL 32726(352) 589-6424Dr. Patrick Ward101 E. Maud Street, Tavares, FL 32778(352) 253-9348Lakeview Internal Medicine, P.A.101 S. 11th Street, Suite 4Leesburg, FL 34748(352) 460-4004CounselorsPsychiatristsAdvanced Behavioral Health CenterDr. Luis Torres1799 Salk Ave., Tavares, FL 32778(352) 742-8300Ms. Peggy Keene301 N. Baker St. Suite 213Mount Dora, FL 32757(352) 742-0069Associates for Counseling Services, P.A.217 N. 14th Street, Leesburg, FL 34748(352) 365-1098Dr. Hector Deleon221 N. Joanna Ave., Tavares, FL 32778(352) 742-8300Psychologists4
LOCAL MEDICAL RESOURCESCardiologistsOral SurgeonFlorida Heart & Vascular Center511 Medical Plaza Drive #101Leesburg, FL 34748(352) 728-6808Dr. Ed Blanton2149 US Hwy 441, Leesburg, FL 34748(352) 728-6600Lake Heart & Medical Center732 N. 3rd St., Leesburg, FL 34748(352) 728-2532Central Florida Oral & MaxillofacialSurgery265 Hatteras Ave., Clermont, FL 34711(352) 242-5331NeurologistsEar, Nose, & ThroatLake Neurology ClinicDr. Marilyn Patterson608 S. 9th Street, Leesburg, FL 34748(352) 360-1122Lake Ear, Nose, Throat & Facial PlasticSurgery AssociatesMedical Plaza 901, 601 E. Dixie Ave. Leesburg,FL 34748(352) 728-2404Neurological Associates of Lake County601 Medical Plaza Drive, Leesburg, FL 34748(352) 787-7611DermatologistsAllergists/AsthmaLake Dermatology1132 E. North Blvd., Leesburg, FL 34748(352) 365-6650Dr. Thomas Shen8245 CR 44 Leg A, Leesburg, FL 34748(352) 314-2929DentistsAdvanced Dermatology1816 Salk Ave.Tavares, FL 32778(352)343-2461Main Street Dentists606 W. Magnolia Street, Leesburg, FL 34748(352) 787-4800Dr. Michel Snyder608 S. 9th Street, Leesburg, FL 34748(352) 787-4532The Dental Touch918 East Dixie Ave.Leesburg, FL 34748(352)728-8300ChiropractorsLake Chiropractic Clinic1235 W. Dixie Ave., Leesburg, FL 34748(352) 787-2785Leesburg Chiropractic Center1107 W. North Blvd. #23, Leesburg, FL 34748(352) 787-45005
LOCAL MEDICAL RESOURCESWomen’s HealthHospitalsAdvanced OB/GYN Associates1414 West Main St.Leesburg, FL 34748(352)728-3898Leesburg Regional Medical Center600 East Dixie DriveLeesburg, FL 34748(352) 323-5762Leesburg Community Health Center225 N. 1st Street, Leesburg, FL 34748(352) 360-0490Florida Hospital—Waterman1000 Waterman WayTavares, FL 32778(352) 253-3600NutritionistsRadiologyJeff Whitman914 N. 14th St., Leesburg, FL 34748(352) 365-6477David Frerking915 E. Alfred Street, Tavares, FL 32778(352) 343-9275WellnessLRMC Wellness Center700 N. Palmetto St.Leesburg, FL 34748(352) 323-5640LabsAdvanced Imaging Center211 N. First St.Leesburg, FL 34748(352)435-0111Lake Medical Imaging801 E. Dixie AveLeesburg, FL 34748(352)787-5858PharmaciesBurry’s Pharmacy500 Webster St., Leesburg, FL 34748(352) 787-3787Quest DiagnosticsPatient Service Center101 South 11th St., Suite 2Leesburg, FL 34748(352) 787-5721Hours: Monday-Friday7:00 a.m. to 4:00 p.m.STARx Pharmacy802 East Dixie Ave., Leesburg, FL 34748(352) 323-9555Lab Corp of America601 E. Dixie Ave. Suite 804Leesburg, FL 34748(352) 319-8013Hours: Monday-Friday7:00 a.m. to 4:00 p.m.CVS/Pharmacy1235 N. 14th Street, Leesburg, FL 34748(352) 787-7800Publix PharmacyHwy 27 (14th Street), Leesburg, FL 34748(352) 787-0664Walgreens901 S. 14th Street, Leesburg, FL 34748(352) 787-3506/Prescriptions6
LOCAL MEDICAL RESOURCESCont. PharmaciesMcHills Pharmacy4120 Corley Island Rd.Leesburg, Florida 34748(352)460-4057Dr. Martin UgwuExpress Pharmacy Leesburg1450 N. Boulevard EastLeesburg, Florida 34748(352)460-0542Walk-In Care CentersCentral Florida Express Care501 North Blvd.Leesburg, FL 34748(352) 431-3743STARx Urgent Care802 East Dixie Ave., Leesburg, FL 34748(352) 323-9555Express Care of Leesburg2500 Citrus Blvd.Leesburg, FL 34748(352) 728-5335US Health Works210 South Lake St Suite 4Leesburg, FL 34748(352)787-4977Lake Regional Urgent Care8404 U.S. Highway 441Leesburg, FL 34788(352)315-88817
Date:Medical History & Emergency Contact FormPersonal Data – please print legibly in blue or black ink.Name:Last MaleFirst FemaleInitialDate of Birth:MonthDayYearHeight:Weight:Email:Cell Phone:Will reside in campus housing?Year/Term: 20 YES NO Spring FallEmergency Contact:Phone 1:Phone 2:Personal Medical History – please print legibly in blue or black ink.If yes, please specify. Include medications, insect bites, environmental factors and food allergies.Do you have any allergies? Yes NoDo you smoke? YesDo you consume alcohol? No YesDo you use other tobacco products? Yes No NoPlease indicate below if you are being treated or have been treated in the past for any of the following and indicate the year.YEARYEAR ADD/ADHD Epilepsy, Seizures (if yes read Beacon CollegeSeizure Protocol & complete Seizure ActionPlan) Alcohol/Drug Dependency Head Injury Anemia, Blood Disease Heart Murmur/Disease Anxiety/DepressionArthritis, Joint Disease, Bone Disease HepatitisHigh Blood Pressure Asperger’s DisorderAsthmaBipolar DisorderBlood Clot/PhlebitisCancerChicken PoxDiabetes (indicate type)Digestive Disorder Hypoglycemia (low blood sugar)Lyme DiseaseMalariaMigrainesRheumatic FeverSchizophreniaThyroid DiseaseTuberculosisDate of Diagnosis/Dateof last seizure/Personal Physician:NameAddressAre you currently under the care of any clinical practitioner for any other medical conditions?Phone Yes NoMedications (include birth control, vitamins, herbs and dosage, times/day, a.m./p.m., etc.):List operations and/or hospitalizations (include reason and year):Mental Health History: Please answer all questionsHave your academic and/or work activities ever been interrupted because of mental health or emotional problems?Please explain:Have you ever been treated with any medication for psychiatric reasons?Please explain:Have you ever been hospitalized for mental or emotional problems?Please explain: No Yes No Yes No YesSignature: Date:
Physical ExaminationTO BE COMPLETED BY HEALTH CARE PROVIDERTO THE EXAMINER: Please review the student’s history and complete the following PhysicalExamination form. Please comment on all positive findings and be sure all information iscomplete.Name:Sex: Male Female Date of Birth: / /Blood Pressure:Pulse:Weight: Height:Visual Acuity: OD 20/ OS 20/ Corrective Lenses:ANY ABNORMALITIES OF:YNExplainSkinHead, Eyes, Ears, Nose, ThroatNeck, JointsNeurologicalMental StatusList Current Medications: N/AList Allergies (Medications/Environmental/Food):Surgical History:Mental Health History:Full unlimited athletic participation: Yes No Explain:Date Medical Providers Signature/Stamp:
TUBERCULOSIS RISK QUESTIONNAIREStudent NameDate of BirthLastFirstMIYESNO1. To the best of your knowledge have you ever had close contact withanyone who was sick with tuberculosis (TB)?2. Were you born in one of the countries listed below?3. Have you traveled or lived for more than one month in one or more ofthe countries listed below?COUNTRIES WITH HIGH RATES OF TUBERCULOSIS (TB)** World Health Organization. TB burden estimates & Global TB report ladeshBelarusBelizeBeninBhutanBolivia (PlurinationalBosnia and HerzegovinaBotswanaBrazilBrunei DarussalamBurkina FasoBurundiCambodiaCameroonCape VerdeCentral African RepublicChadChinaChina, Hong Kong SARCongoCôte orEquatorial urasIndiaIndonesiaKazakhstanKenyaKiribatiLao carMalawiMalaysiaMaliMarshall ueMyanmarNamibiaNepalNicaraguaNigerNiueNorthern Mariana IslandsPakistanPalauPanamaPapua New GuineaPeruPhilippinesRepublic of KoreaRepublic of MoldovaRomaniaRussian FederationRwandaSao Tome and PrincipeSenegalSierra LeoneSolomon IslandsSomaliaSouth AfricaSouth SudanSri TurkmenistanTuvaluUgandaUkraineUnited Republic ofUzbekistanVanuatuViet enistanTuvaluUgandaUkraine If you answered YES to any of the above questions, you are considered “high-risk” and arerequired to submit documentation of recent PPD testing on the Immunization form. PPD testingshould be within the last 12 months.If the Mantoux PPD test is positive ( 10mm), you must submit a copy of a chestx- ray report in English dated within the last 6 months.Please note: If you have had a positive tuberculin skin test in the past, you do not needanother test. Please note prior treatment completed.Name: Date:
Leesburg Family Medicine 802 East Dixie Ave., Leesburg, FL 34748 (352) 787-1324 Dr. Rolando Menendez 608-A South 9th St., Leesburg, FL 34748 (352) 365-2221 Leesburg Community Health Center 225 N. 1st Street, Leesburg, FL 34748 (352) 360-0490 Lake County Health Department 14 N. Eustis Street, Eustis, FL 32726 (352) 589-6424 Lakeview Internal .
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