VACCINE APPOINTMENT FORM 2026

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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.
Appointment Calendar
Routine Appointment - at Health Department (400 E Babcock Street)

Patient Demographics
Is this appointment for a student?
Which school?
Patient name

First NameLast Name
Patient Date of Birth

MonthDayYear
2 digit month, 2 digit day, 4 digit year
Patient Age
If under 1 year of age, please enter 0.
Patient sex assigned at birth
Patient gender
Language spoken
Language
Will you need an interpreter at your appointment?
Patient race
Patient ethnicity
In the last 6 months

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
Contact Preference

Health Insurance Information
Do you have health insurance?
Great — we will bill your insurance for your vaccines. Thank you for helping us keep our clinic running!

Please note: Those with Medicare Part D plans will be asked to pay the patient portion not covered at the time of service.
If no: We can offer low- and no-cost for some vaccines today because of limited grant funding. The admin cost per vaccine is $21 each.
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
2 digit month, 2 digit day, 4 digit yearDate
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

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I can pay:

Other amount per vaccine

Vaccine Programs
If you do not have insurance or your insurance does not cover vaccines, we have programs to help reduce the cost of routine immunizations.

These programs have limited funding and only cover the vaccines listed below. Other vaccines are not covered by these programs.

Children: Vaccines for Children (VFC)

Who qualifies?
Children ages 0–18 who are uninsured, underinsured, or enrolled in Medicaid.

Vaccines covered:
DTaP • Tdap • IPV • MMR • Varicella • Hepatitis A • Hepatitis B • Hib • HPV • Meningococcal (ACWY and B) • Pneumococcal • Rotavirus • Influenza • COVID-19

Fee: $21 per vaccine. Your selected amount will be applied toward this fee.

Adults: Vaccines for Adults (VFA)

Who qualifies?
Adults 19 and older who are uninsured or underinsured (their insurance does not cover vaccines).

Vaccines covered:
MMR • Hepatitis A • Hepatitis B • Twinrix (Hepatitis A/Hepatitis B) • Influenza • Tdap • HPV • COVID-19 • PCV20 (Pneumococcal) • Mpox

Fee: $21 per vaccine. Your selected amount will be applied toward this fee.

Please note: If the vaccine you need is not listed above, it is not covered by these programs and would need to be paid for out of pocket.

View our vaccine price list here
Without insurance, most routine vaccines cost $21 each. Would this cost make it hard for you to get vaccines today?
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

Billing Practices Acknowledgement
I understand that I am responsible for any charges not covered by insurance, state programs, grant programs, or other funding sources. If applicable, I understand that my charges will be billed according to the sliding scale fee based on my income. I authorize payment of medical benefits to the county health department for the services provided.

Required and Recommended Vaccines
📚 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!
  📅 2026 Recommended Immunizations for Birth–6 Years Old
- 7–18 years: Older kids and teens need vaccines too!
  📅 2026 Recommended Immunizations for Ages 7–18
- 19+ years: You're never too old to get vaccinated!
  📅 2026 Recommended Immunizations for Adults 19 and Older

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.
Vaccine(s) requested

Other
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
Do you have access to a copy of your immunization records? (screenshots or paper documentation)
Please upload your immunization records here

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Would you like us to contact you for additional support to locate and compile your immunization records?
Tips for Locating Old Immunization Records

Post-Vaccination Observation Acknowledgement
For your safety, we recommend that everyone who gets a vaccine stays for 15 minutes. This short wait helps us respond quickly in case of fainting or an allergic reaction.

Patient Privacy Practices
Please review our Notice of Patient Privacy Practices: Notice of Privacy Practices
I have reviewed the Notice of Privacy Practices, which provides a description of information uses and disclosures.

Consent for Services
Consent for imMTrax

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.
Release of Immunization Information Consent for K-12 Students

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.
Consent for Vaccination - You Must Sign This to be Vaccinated

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 and type your name below
Patient (over age 18) or Parent/Guardian - Please type your name

First NameLast Name
Today's Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
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

Vaccine Programs

Sliding Fee Scale

Billing Practices Acknowledgement

Required and Recommended Vaccines

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