VACCINE APPOINTMENT FORM 2026

Vaccine Appointment Form
Temporary Address:

400 East Babcock Street, Bozeman, MT 59715

** 2 hour free parking lot on the corner of Babcock and Rouse.

Please use our Westside entrance on Rouse.

** Hay estacionamiento gratuito por 2 horas en la esquina de la Calle Babcock con la Avenida Rouse.

Utilice nuestra entrada oeste en Rouse.
¿Hablas español?

Presione la bandera en la esquina superior derecha y cambie a español.
Appointment Calendar
Routine Appointment - at Health Department (400 E Babcock Street) *

Patient Demographics
Patient name*

First NameLast Name
Patient Date of Birth*

MonthDayYear
Patient Age*
If under 1 year of age, please enter 0.
Patient sex assigned at birth*
Patient gender
Language spoken*
Language
YesNo
Patient race*
Patient ethnicity*
I've been seen at the Gallatin County Health Department and my contact information and insurance are the same.I've been seen at the Gallatin County Health Department and my contact or insurance information has changed.This is my first visit to the Gallatin County Health Department.

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.Format: (000) 000-0000.
Address*

Street Address

Street Address Line 2

CityState

Zip Code
Voice MailSMS 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.
Please note: If you do not have insurance, we have a state immunization program to cover the fees of certain vaccines.
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. If you have Medicare, please include a copy of your red, white, and blue Medicare card.
Front of card
Back of card
Upload a digital copy of your insurance card

Cancelof

Cost of Routine Vaccinations
💳 Most health insurance plans cover the cost of vaccines.

If you don’t have insurance—or if your insurance doesn’t cover vaccines—we have programs to help reduce the cost of routine immunizations.

VACCINES FOR CHILDREN PROGRAM (VFC)

📋Eligibility: Children ages 0–18 who are uninsured, underinsured, or on Medicaid.

💉 Vaccines available:
DTaP, Tdap, IPV, MMR, Varicella, HepA, HepB, Hib, HPV, Meningococcal (ACWY and B), Pneumococcal, Rotavirus, Influenza, and COVID-19.

💲Administrative fee: $21 per vaccine (sliding fee scale available).

VACCINES FOR ADULTS PROGRAM (VFA)

📋Eligibility: Adults 19+ who are uninsured or underinsured (insurance doesn’t cover vaccines).

💉 Vaccines available:
MMR, HepA, HepB, TWINRIX (HepA/HepB), Influenza, Tdap, HPV, COVID-19, PCV20 (Pneumococcal), and Mpox (Monkeypox).

💲Administrative fee: $21 per vaccine (sliding fee scale available).

⚠️ Note: Due to limited funding, these programs only cover the vaccines listed above.

Paying Out of pocket? View our vaccine price list here
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) *

Please list all household members supported by this income - INCLUDING YOURSELF *

Rows	First Name	Last Name	Date of Birth	Relationship	Income
1
2
3
4
5
6
7
8
9
10

📚 Required Vaccines for School & Childcare Attendance in Montana:
- 🏫 K-12 Immunizations
- 🧸 Childcare attendance
Recommended Routine Vaccines by Age Group:
- Birth–6 years: Your child needs vaccines as they grow!
  📅 2025 Recommended Immunizations for Birth–6 Years Old
- 7–18 years: Older kids and teens need vaccines too!
  📅 2025 Recommended Immunizations for Ages 7–18
- 19+ years: You're never too old to get vaccinated!
  📅 2025 Recommended Immunizations for Adults 19 and Older
YesNo
Which school? *

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.

Vaccines Requested
⚠️ Travel-related vaccines (including Typhoid, Cholera, Japanese Encephalitis, Rabies (travel indication), Yellow Fever, Tick-borne Encephalitis [Ticovac], and Chikungunya) are not scheduled through this form.

📌 If you require any of these vaccines, please complete the International Travel Consult Appointment Form instead.
Vaccines for childcare or school attendance (such as Hib, DTap/TDap, MMR, varicella, polio)Routine vaccines for age (such as Hepatitis A/B, TDap, HPV)Flu 2025-2026 vaccineCOVID 2025-2026 VaccineOther
If other, please describe:

Important Information - Please Read Before Continuing
Before selecting any vaccines, you are required to review the Vaccine Information Statements (VIS) and/or Emergency Use Authorization (EUA) fact sheets for the vaccine(s) you may receive. These documents explain:
- The disease(s) the vaccine(s) prevent
- The risks and benefits of the vaccine(s)
- 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.

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 receiving 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:

Vaccine Appointment Form

Appointment Calendar

Patient Demographics

Contact Information

Health Insurance Information

Health Insurance Card

Cost of Routine Vaccinations

Sliding Fee Scale

Billing Practices Acknowledgement

Vaccines Requested

Important Information - Please Read Before Continuing

Vaccines Requested & Vaccine Information Statements

Acknowledgement Questions

Immunization Records

Post-Vaccination Observation Acknowledgement

Patient Privacy Practices

Consent for Services