Seasonal Vaccine Consent & Registration Form

Do you have allergies?

Please list all of your allergies

If no allergies type "None"

Please list all of your allergic reactions to each allergy

Patient Name

First NameLast Name

Date of Birth

Must be 12+ years of age for completing this form.

Address

Street Address Including Apartment Number

City

State/ProvincePostal/Zip Code

County of Residence i.e., Platte, Clay, Jackson, etc.

Home Phone Number

Please enter a valid phone number. If no home phone, please put your cell phone number.Format: (000) 000-0000.

Cell Phone Number

Please enter a valid phone number. If no cell phone, please put your home phone number.Format: (000) 000-0000.

Race

Ethnicity

Sex

Insurance Type

Medicaid DCN #

Medicare #

Name of Primary Health Insurance

Name of Policy Holder

Policy Holder Phone Number

Please enter a valid phone number.Format: (000) 000-0000.

Policy Holder Date of Birth

Date

Policy Holder Address:

Address

Policy or Member Numbers

Group Number

Customer Service Number on the Back of the Insurance Card

Please enter a valid phone number.Format: (000) 000-0000.

Personal Financial Responsibility: By signing this form, and in return for the services rendered by the Platte County Health Department (PCHD), I am personally responsible for all fees not paid by any third party on my behalf.

Assignment of Insurance Benefits: I hereby assign all my interest and rights to all insurance benefits otherwise payable to me from any policy to PCHD. I agree that PCHD may disclose any portion of my medical, financial, or personal information to any person or organization requiring such information as a condition of paying, receiving payment for, or justifying payment for my health care or the health care of one for whom I am responsible. I further authorize payment of all insurance benefits, otherwise payable to me, for all treatment provided directly to PCHD. I understand that I am responsible for any amount not covered by insurance.

My signature indicates that I have reviewed a copy of the “Notices of Privacy Practices” and have read the Vaccine Information Statement (VIS) for the vaccine(s) that I am requesting be given to the person named on the form.

Signature of Patient, Parent, or Legal Guardian (Use mouse, stylus, or finger to sign)

Printed Name of Patient, Parent or Legal Guardian

Date Signed

Date

Relationship to Patient

(Self, Parent, Legal Guardian)

Seasonal Vaccine Consent & Registration Form

Health History Screening Tool

Health History