2025 Employee Vaccine Clinic Consent (Public Schools)

Employee Vaccine Clinic Consent (Public Schools) 2025

Patient Registration Form
Employee's Legal Last Name*
Employee's Legal First Name*
Employee's Date of Birth*

MonthDayYear
Employee's Primary Language*
Employee's Address*

Street Address

Street Address Line 2

CityState

Zip Code
Employee's Race*
Employee's Ethnicity*
Employee's Gender at Birth*
Employee's Marital Status*
Employee's Phone Number*
Please enter a valid phone number.
Employee's Email*
example@example.com
Place of Employment*
Does the employee have health insurance/Medicaid?*
If YES, the employee has health insurance/Medicaid:

Complete the questions below.
What is the name of the health insurance/Medicaid provider?
:
What is the last name of the insurance policy holder?
Type the last name.
What is the first name of the insurance policy holder?
Type the first name.
How is the policy holder related to the patient?
What is the birth date of the policy holder?

MonthDayYear
Date
What is the gender of the policy holder?
What is the address of the insurance policy holder?

Street Address

Street Address Line 2

CityState

Zip Code
What is the insurance policy holder's phone number?
Please enter a valid phone number.
What is the Member ID Number/Subscriber Number?
For Tricare, use benefits number on back of CAC card.
What is the Group Number?
Attach a photo or scanned copy of the FRONT of the health insurance card.

Cancelof
Attach a photo or scanned copy of the BACK of the health insurance card.

Cancelof
General consent for treatment

By signing below, I hereby authorize the County Health Department to render the appropriate services and presumptive treatment to me at my request. I understand that to render care, the staff may need to examine, conduct tests or diagnositc procedures, administer medicines or treatments. I understand that I will have an opportunity to ask my healthcare provider questions regarding such care and read any informational materials given to me as deemed appropriate. I acknowledge that all of the information I have provided to the County Health Department staff is true and accurate to the best of my knowledge.

Vaccine(s) given to me will be administered by a licensed nurse. I understand that the vaccine(s) received are recommended by the Center for Disease Control (CDC) for the prevention of the disease indicated.
Signature*

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I (please check all boxes that apply):*

Am not allergic to eggs, egg protein, gentamicin, latex, gelatin, arginine, yeast, or any vaccine.Have never had a serious reaction to vaccines.Do not have a history of Guillain-Barre' Syndrome, seizures, epilepsy, or encephalopathy.Have not had a fever of 101 degrees or more in the past 24 hoursHave not any life-threatening allergies
If the answer to any of the above allergy/reaction questions is YES, please list and explain below.
Signature*

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North Central Health District Notice of Privacy Practices

Acknowledgement of Receipt of Notice of Privacy Practices

I acknowledge that I have reviewed and understand the Notice of Privacy Practices for the North Central Health District. The Notice sets forth the ways in which my personal health information may be used or disclosed by the North Central Health District or the County Health Department and outlines my rights with respect to such information.
Signature*

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Date

MonthDayYear
Date
Should be Empty:

Employee Vaccine Clinic Consent (Public Schools) 2025

If YES, the employee has health insurance/Medicaid: