PATENT INFRINGEMENTS AT INTERNATIONAL FAIRS CROSS-BORDER ENFORCEMENT THROUGH BELGIAN SUMMARY PROCEEDINGS IN HER RULING OF 25 MARCH 2005, THE PRESIDENT OF THE BRUSSELS DISTRICT COURT ISSUED A CROSS-BORDER INTERIM INJUNCTION AGAINST TWO COMPANIES, ONE BRAZILIAN AND THE OTHER SOUTH KOREAN, WHICH HAD INFRINGED THE PATENT RIGHTS OF THE GERMAN PHARMACEUTICAL COMPANY ALTANA PHARMA AT AN INTERNATION
Gsis.sc.kr2Gyeonggi Suwon International School Entrance Health Form
Date of Birth
Permission for giving medication for minor complaints
Acetaminophen (Tylenol) (for minor aches, menstrual cramps or headache etc…)
Pepto Bismol ( for nausea, diarrhea, stomachache or heartburn etc…) I give permission for my child to be given medication at the nurse’s discretion.
Parent’s Signature_______________________________ Date_______________________________________
Permission for Emergency Treatment
In the event that I cannot be reached in an emergency, I give permission for my child to receive medical treatment,
including transport to the most accessible hospital, as deemed necessary by school authorities.
Parent’s Signature_______________________________ Date______________________________________
(To be completed and signed by parents/guardian and verified by healthcare provider)
Student’s name________________ Date of Birth_________________ Sex; male_____ female_____ Grade__________ ALLERGIES (Food, drug, insect, other)
MEDICATION (List all prescribed or taken on a regular basis)
Head Injury/Concussion/Passed out? Yes No Dizziness or chest pain with exercise? Yes No Bone/Joint problem/Injury/Scoliosis? Yes No
Information may be shared with appropriate personnel for health and educational purposes.
Parents/Guardian: Signature_________________________________________ Date_____________________________________
(below this page to be completed by Healthcare provider or Physical doctor)
Student’s name__________________________ Date of Birth_______________Sex; male_________female________Grade__________ VACCINE/DOSE
or DTaP) Diphtheria and Tetanus(Pediatric DT or Health care provider verifying above immunization history must sign below.
Signature ____________________________________ Title ___________________________________________ Date ______________________________________
Alternative proof of immunity
Clinical diagnosis is acceptable if verified by physician.
Measles(Rubeola) ____________________ Mumps _____________________ Vericella ______________________ Physician’s Signature _______________________________
Month/Day/Year Month/Day/Year Month/Day/Year
Student’s name______________________ Date of Birth____________________ Sex; male_________ female________ Grade__________
HIGHT_______________________ WEIGHT__________________________ BP______________________
TB SCREENING; TB SKIN TEST ________________________________ or CHEST X-RAY________________________________
LAB TESTS*recommended only Date
SPECIAL INSTRUCTIONS/DEVICES e.g. safety glasses, glass eye, chest protector for arrhythmia, prostatic device, dental bridge,
false teeth, athletic support/cup
MENTAL HEALTH/OTHER Is there anything else the school should know about this student?
If you would like to discuss this student’s health with school or school health personnel. Check title ; nurse___ teacher___ counselor___
EMERGENCY ACTION needed while at school due to child’s health condition (e.g. seizures, asthma, insect sting, food, peanut allergy,
bleeding problem, diabetes, heart problem)?
Yes_______ No_______ If yes, please describe.
On the basis of the examination on this day, I approve this child’s participation in (If no or modified attach explanation.)
PHYSICAL EDUCATION Yes____ No_____ Modified___ INTERSCHOLASTIC SPORTS(for one year) Yes____ No____ Limited____
Printed name: Signature: Date:
On the day when you schedule your in-office procedure you will sign a surgical consent form that reviews the risks of the specific procedure that you are planning. You will be given your prescriptions at this visit and a copy of this instruction sheet. If your scheduling is handled by phone then your prescriptions will be mailed to you. 1-2 Days Prior to procedure: Begin taking the Ibuprofen (Mo