MMR Vaccine Appointment Form

Drive-Up MMR Vaccine Appointment Form
Gallatin County Fairgrounds

901 N. Black Ave, Bozeman MT 59715

Exhibit 1
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MMR Vaccine Recommendations

Infants 6 months through 11 months	1 early MMR dose (does not count towards primary series)
Children 12 months through adults born in 1957 or later	2 doses of MMR (2nd dose now if more than 28 days since dose 1)
Adults born 1957-1968 (special cohort)	2 doses of MMR*
Adults born before 1957	Considered immune

* Adults born 1957-1968 may have recieved the inactive MMR vaccine. Please check your records for 2 doses of live vaccine.

📌 Tip: If you're unsure whether you've had the MMR vaccine, check with your healthcare provider or immunization records. When in doubt and documentation is unavailable, it is safe to receive the vaccine.

Questions? Call 406-582-3100, option 1

Vaccine Appointment Form
YesNo
Yes, the patient has changesNo, no changes to demographic or health insurance information
Patient Name*

First NameLast Name
Date of birth*

MonthDayYear
Date
What day and time would you prefer?
YesNo
Which school? *
YesNo

Measles Screening
We are screening every person for signs and symptoms of measles due to numerous public exposure sites.

Public Exposure Sites (scroll down to Active Public Exposure Sites)
YesNo
YesNo

Patient Demographics
Patient name*

First NameLast Name
Patient Date of Birth*

MonthDayYear
Patient Age*
If under 1 year of age, please enter 0.
What is your sex assigned at birth?*
What is your gender?
Language spoken at home*
Language
What is your race?*
What is your ethnicity?*
Contact Information
Email*
A confirmation of your appointment will be sent to the email address entered above.
Phone Number*
Please enter a valid phone number.
Address*

Street Address

Street Address Line 2

CityState

Zip Code
Voice Mail/TextEmailMailNo Calls

Health Insurance Information
YesNo
Please note: Those with Medicare Part D plans will be asked to pay the patient portion not covered at the time of service.
Insurance Company Name*
Member ID Number*
Group Number*
(Type "none" if one is not listed)
Policy Holder Name*

First NameLast Name
Policy Holder Date of Birth*

MonthDayYear
Date
Policy Holder Relation to Client*
Health Insurance Card

If you're able, please take a photo of the front and back of your insurance card or upload a digital copy
Front of card
Back of card
Upload a digital copy of your insurance card

Cancelof
Cost of Routine Vaccinations
Yes, please show me the Sliding Fee Scale.No, I can pay $21.00 per vaccine.
Sliding Fee Scale

Depending on your reported income, we can slide the cost of vaccines to low or no cost. This opportunity is available through a state grant and may not be available in the future.
What is your total gross monthly income? *
How many people are supported by this income? (This number includes you, your spouse, and/or dependents) *

Billing Practices Acknowledgement
Yes, I understand the billing information.No, I don't understand the billing information and would like to speak with a billing specialist.

Important Information - Please Read Before Continuing
You are required to review the Vaccine Information Statements (VIS) for the MMR vaccine. These documents explain:
- The diseases the vaccine prevents
- The risks and benefits of the vaccine
- Possible side effects and what to expect after vaccination
It is your responsibility to review this information so you can make an informed decision about vaccination.

The following page will include the statements and include an acknowledgement question.

Vaccine Information Statement (VIS) - Please Review
Current MMR VIS
Acknowledgement Questions
YesNo
YesNo
Yes, I have questions and would like additional information during the appointment.No, I do not have questions about the VIS/EUA.

Immunization Records
YesNo
Please upload your immunization records here

Cancelof
YesNo
Tips for Locating Old Immunization Records

Post-Vaccination Observation Acknowledgement
I agree (or agree on behalf of the person receieving the vaccine) to stay for 15 minutes after the vaccine.I prefer not to stay (or decline on behalf of the person receiving the vaccine).

Patient Privacy Practices
Please review our Notice of Patient Privacy Practices: Notice of Privacy Practices
YesNo

Consent for Services
Yes, I consent to the shared use of demographic information and authorize my immunization records to be recorded into the State of Montana Immunization Registry for immunization health purposes and that it may be released to health care providers, childcare providers and schools across the state that may provide continuing immunization services. I understand that I can revoke this authorization and have my record removed at any time by contacting my local county health department.No, I do not consent to the above statement.
I give permission for my child's school to release the following information concerning my child to the Gallatin-City County Health Immunization Program: Name, Date of birth, Immunization history, Parent/guardian contact information. The school and the Immunization Program will collaborate and use this information to: review your child's immunization history, notify you if immunizations are due for school attendance, and provide opportunities to vaccinate your child at local or school-based clinics. This consent will be in effect as long as your child is enrolled in this school system and can be reversed at any time by sending a written note to your child's school.No, I do not consent to the above statement.N/A - I am not a K-12 student.
By signing this form, I am requesting vaccination services for myself and/or the persons identified, of whom I am authorized to sign. A copy of the appropriate Centers for Disease Control and Prevention Vaccine Information Statement(s) or Emergency Use Authorization(s) has been provided. I have read the information about the disease(s) and the vaccine(s) listed. I believe that I understand the benefits and risks of the vaccine(s) cited and ask that the vaccine(s) listed be given to me or to the person named (for whom I am authorized to make this request).
Patient (over age 18) or Parent/Guardian - Please sign your name here*

Clear
If you are unable to sign your name, please type your name below

First NameLast Name
Today's Date

MonthDayYear
Date
Relationship to Patient*
Comments, questions, or concerns:
Should be Empty:

Rows	Yes	No	N/A
Is the person getting vaccinated sick today, or have/had an acute illness with fever within the last 24 hours?
Does the person getting vaccinated have allergies to medications, food, vaccine component, or latex?
Has the person getting vaccinated had a serious reaction after receiving a vaccine such as convulsions, seizures, or Guillain-Barre Syndrome?
Has the person getting vaccinated been diagnosed with a heart condition (myocarditis or pericarditis) or have had Multisystem Inflammatory Syndrome (MIS-A or MIS-C) after an infection with the virus that causes COVID-19?
Does the person getting vaccinated have: Cancer, Immune System Problems, HIV/AIDS, Heart Disease, Kidney Disease, Metabolic Disease, Diabetes, Lung Disease, Asthma, Anemia, Other Blood Disorders, No Spleen, a cochlear implant, a spinal fluid leak, Long term aspirin therapy?
Has the person getting vaccinated received any vaccinations in the last 4 weeks?
In the past year has the person getting vaccinated ever received immune (gamma) globulin, blood/blood products or an antiviral drug?
Has the person being vaccinated, a sibling, or a parent had a seizure or other nervous system problems?
In the past 6 months has the person being vaccinated taken medications that affect your immune system, such as prednisone, other steroids, or anticancer drugs; drugs for the treatment of rheumatoid arthritis, Crohn’s disease, or psoriasis; or have had radiation treatments?
Is it possible that the person being vaccinated is pregnant or may become pregnant in the next month?
For babies: is there a history of intussusception?
For children ages 2-4 years: Has a healthcare provider told you that the child had wheezing or asthma in the past 12 months?
Has the patient ever felt dizzy or faint before, during or after a shot?
Is the patient getting vaccinated anxious about getting a shot today?

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Drive-Up MMR Vaccine Appointment Form

Vaccine Appointment Form

Measles Screening

Patient Demographics

Contact Information

Health Insurance Information

Health Insurance Card

Cost of Routine Vaccinations

Sliding Fee Scale

Billing Practices Acknowledgement

Important Information - Please Read Before Continuing

Vaccine Information Statement (VIS) - Please Review

Current MMR VIS

Acknowledgement Questions

Immunization Records

Checklist for Vaccine Administration

Post-Vaccination Observation Acknowledgement

Patient Privacy Practices

Consent for Services