• Immunization Clinic Registration

    Inscripción por la Clínica de Inmunización

     

    Location:

    Cass County Health Department

    1411 South Commercial Street

    Harrisonville, MO 64701

    816-380-8425

     

    **Disclaimer: Signing up on this form does not guarantee a specific time or date, this form allows us to pre-register your information in hopes to lessen your wait time upon arrival to our clinic.**

    ** Aviso: Firmar en este documento no garantiza un día o tiempo específico. Este documento no más nos permite a obtener su información para ayudar a disminuir su tiempo de espera cuando llegue a la clínica.**

  • Date of Birth (Fecha de Nacimiento) *
     - -
    2 digit month, 2 digit day, 4 digit year
  • Sex*
  • Race (Raza)*
  • Ethnicity (Origen Étnico)*
  • Preferred Language*
  • Format: (000) 000-0000.
  • Do you have health insurance? (Click no if your insurance plan does NOT cover vaccinations) ¿Tiene seguromédico? (Haga clic en "no" si su plan de seguro NO cubre las vacunas)*
  • What type of insurance do you have? (tipo de seguro)*

  • For self-pay patients, an administration fee is due at the time of service ($20 for the first vaccine, add $5 for each addititional vaccine).

    ($20 por la primera vacuna, agregue $5 por cada vacuna adicional).

     

    *Based on vaccine avilablity, additonal charges may apply* 

    (*Según la disponibilidad de vacunas, pueden aplicarse cargos adicionales*)

  • Format: (000) 000-0000.
  • Front of Insurance Card (Frente de la tarjeta de seguro) 
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  • Back of Insurance Card (Reverso de la tarjeta de seguro) 
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  • Is the patient sick today? (¿Está enfermo el paciente hoy?)*
  • Has the patient had a fever in the last 2 days? (¿El paciente ha tenido fiebre en los últimos 2 días? )*
  • Does the patient have any allergies to food, medication or vaccines? (¿Tiene el paciente alguna alergia a alimentos, medicamentoso vacunas?)*
  • Has the patient had a serious reaction to a vaccine in the past? (¿Ha tenido reacciones graves a alguna vacuna en el pasado?)*
  • Does the patient have seizures? (¿El paciente presenta convulsiones?)*
  • Has the patient had a health problem with heart, lung, kidney or blood disorder, or suffered from intussusception as an infant? (¿El paciente ha tenido algún problema de salud relacionadocon el corazón, los pulmones, los riñones o la sangre, o ha sufrido invaginación intestinal cuando era un bebé)*
  • Does the patient have cancer, leukemia, HIV/AIDS, or any other immunosuppressive condition? (¿El paciente tiene cáncer, leucemia, VIH/SIDA o alguna otra condición inmunosupresora?)*
  • Has the patient taken cortisone, prednisone or other steroids, anticancer drugs or had radiation treatments in the past 3 months? (¿El paciente ha tomado cortisona, prednisona u otrosesteroides, medicamentos contra el cáncer o ha recibido tratamientos de radiación en los últimos 3 meses?)*
  • Has the patient received a transfusion of blood, blood products, or been given immunoglobulin within the past year? (¿El paciente ha recibido una transfusión de sangre,productos sanguíneos o se le ha administrado inmunoglobulina en el último año?)*
  • Is the patient pregnant, or is there a chance you could be pregnant during the next month? (¿La paciente está embarazada o existe la posibilidad de que pueda estar embarazada durante el próximo mes?)*
  • Has the patient received any vaccinations in the past 4 weeks? (¿El paciente ha recibido alguna vacuna en las últimas 4 semanas?)*
  • Select patient's age range*
  • I would like the patient to receive: (If you do not know, please choose other) (vacunas)*
  • I would like the patient to receive: (If you do not know, please choose other) (vacunas)*
  • I would like the patient to receive: (If you do not know, please choose other) (vacunas)*
  • I would like the patient to receive: (If you do not know, please choose other)(vacunas)*
  • I would like the patient to receive: (If you do not know, please choose other) (vacunas)*
  • I would like to receive: (If you do not know, please choose other) (vacunas)*
  • Consent: I agree to allow the Cass County Health Department to administer the chosen vaccines to my child. (Consentimiento: Acepto permitir que el Departamento de Salud del Condado de Cass administre lasvacunas elegidas a mi hijo.)*
  • I certify that I have legal permission to make medical decisions on behalf of the patient being registered. (Certifico que tengo permiso legal para tomar decisiones médicas en nombre del paciente que se está registrando.)*
  • Today's Date:*
     - -
    2 digit month, 2 digit day, 4 digit year
  • Should be Empty: