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Public Vaccine Consent Form
Vaccine Information
Vaccine Administration Location
PCHD Walk-In
My Employer
Mobile Clinic
Other
Vaccine(s) to be administered:
*
Flu
Covid
Both
Please enter the name of your Employer
*
Mobile Clinic Location
Bowling Green
Louisiana
Clarksville
Curryville
Frankford
Vandalia
Other
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Patient Information
Name
*
First Name
Last Name
Age
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Date of Birth
*
-
Month
-
Day
Year
Date
Email
example@example.com
Address
*
Street Address
Street Address Line 2
City
Please Select
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
State
Zip Code
County of Residence
*
Gender
*
Male
Female
Ethnicity
*
Non Hispanic
Hispanic
Race
*
Preferred Language
*
Please Select
English
Spanish
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Insurance Information
*
No Insurance or Under insured
American Indian or Alaska Native
Does not apply to me
Enter Name of Insurance
*
if no insurance enter N/A
Member ID
*
if no insurance put NA
Group Number
*
If no insurance put NA
Please Take Photo of the FRONT of your insurance card here
Please Take Photo of the BACK of your insurance card here.
Do you have a Secondary Insurance?
*
Yes
NO
Name of Secondary Insurance
*
Secondary Insurance Member ID
*
Contact Number for Secondary Insurance
Secondary Insurance Group Number
Take Photo of front of Secondary insurance
Take Photo of back of Secondary Insurance Card
If unable to take a picture, you can upload your insurance card(s) here
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Consent Agreement
*
By signing this form, I am stating that I have read or have had explained to me the information on this form. I believe I understand the benefits and risk of the vaccine(s). I have chosen to request the vaccine be given to me or the person named above for whom I authorized the request. HIPPA Notice My signature on this form acknowledges that a copy of the Pike County Health Department Notice of Privacy Practices has been made available to me. I understand that this document provides an explanation of the ways in which my health information may be used or disclosed by Pike County Health Department and of my rights with respect to my health information. I have been provided with the opportunity to discuss concerns I may have regarding the privacy of my health information. Consent to Bill With this signature I acknowledge the receipt of medical services and authorize the release of any medical information necessary to process this claim for health care payment only. I authorize payment to the provider and understand that my claim will be submitted to insurance and that I will be responsible for any deductible, co-payments, coinsurance, or client fees at the time of services. I understand I will receive a statement if my account has a balance due and that the Pike County Health Department is not responsible for collection of my insurance claim or for negotiating a settlement on a disputed claim that I am responsible for payment of my account. Immunization Consent I have been offered, read or had explained to me the "Vaccine Information Statement(s)" about the vaccines being requested today. I understand I will have the opportunity to ask questions and have them answered to my satisfaction. I understand the benefits and risks of the vaccine(s) being requested and ask that the vaccine(s) currently due for which I have signed below be given to me or to the person named above for whom I am authorized pursuant to Section 431.058, RSMo to make this request.
Person Signing Consent
*
Patient
Parent
Guardian
Responsible Party
Verbal Consent Obtained
Name of Parent/Guardian/Responsible Party/who received verbal consent
*
First Name
Last Name
Signature
*
Today's Date
-
Month
-
Day
Year
Date
How did you hear about this event?
*
PCHD E-News
PCHD Website
Radio
Newspaper
Facebook
Snapchat
Other Social Media
Word of mouth
Other
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