Immunization Clinic Registration Form

Name of Person to be Vaccinated*

First NameMiddle NameLast Name

Date of Birth*

MonthDayYear

Age*

Legal Gender*

Mobile Phone Number*

Email*

example@example.com

Physician/Medical Provider Name

Home Address*

Street Address

Street Address Line 2 (Apt #, Suite #, etc.)

CityState

Zip Code

Race*

Ethnicity*

Language*

What school does the child currently attend?*

Does the person to be vaccinated have health insurance?*

YESNO

Primary Insurance Name*

i.e. Anthem, Cigna, United Healthcare. Medicaid, Medicare

Member ID # - Primary Insurance*

Insured Name - Primary Insurance*

Insured Date of Birth*

Secondary Insurance Name

This information is REQUIRED if client has additional insurance

Member ID# - Secondary Insurance

This information is REQUIRED if client has additional insurance

Insured Name - Secondary insurance

This information is REQUIRED if client has additional insurance

Insured Date of Birth

This information is REQUIRED if client has additional insurance

1.) Has the child/teen had a serious reaction to a vaccine in the past?*

2.) Does the child/teen have cancer, leukemia, HIV/AIDS, Sickle Cell Anemia, or any other immune system problem? Has the child had a splenectomy or cochlear implant?*

3.) Has the child/teen received a transfusion of blood or blood products, or been given a medicine called immune (gamma) globulin or an antiviral drug in the last year?*

If YES, please list the blood product or medication given and the date:

4.) Does the child/teen have allergies to medications, foods, a vaccine component, or latex?*

If YES, please list allergies and reactions:

5.) Has the child/teen had a seizure or brain problem or a nervous system problem?*

6.) Has the child/teen taken cortisone, prednisone, other steroids, or anticancer drugs, or had radiation treatments in the past 3 months?*

7.) Have you ever been told the child/teen has or had intussusception?*

8.)Is the child/teen pregnant, or is there a chance she could become pregnant during the next month?*

9.) Has the child/teen received an vaccinations in the last 4 weeks?*

If YES, please list the vaccinations given and on what date:

10.) Does the child/teen have excessive vomiting, diarrhea, or digestive difficulties?*

11.) Has the child/teen had varicella (chickenpox) disease?*

If YES, at what age?

12.) Does the child/teen have a long-term health problem such as asthma, heart disease, kidney disease, liver disease, metabolic disease (i.e. diabetes)or anemia or another blood disorder? Is the child on long-term aspirin therapy?*

13.) Does the child/teen smoke or vape?*

Your child will receive all SCHOOL-REQUIRED immunizations for which they are due today. The child's immunization record will be reviewed in the state immunization registry (CHIRP) prior to administering vaccines. If your child's record is NOT in CHIRP, please contact Kelly Carpenter at 765-456-2408, Option #1 for Nursing to discuss options for providing immunization records. School-required immunizations are listed below with a link to their respective Vaccine Information Statements (VIS):

Tdap -http://tinyurl.com/ayvsnzcf
Meningococcal A,C,W,Y (MCV4) - http://tinyurl.com/bvj248tz
Hepatitis A - http://tinyurl.com/yep84s8a
Hepatitis B - http://tinyurl.com/ys7kaym2
MMR - http://tinyurl.com/ykwbctwz
Varicella - http://tinyurl.com/36kt56v4
Polio -http://tinyurl.com/bde4py7f

They may also be due for other vaccines recommended by the ACIP (Advisory Committee on Immunization Practices). The recommended immunizations your child may be due for are listed below. Please mark whether you want your child to receive each of the recommended immunizations listed below. A link to their respective Vaccine Information Statements (VIS) are listed below:

Please administer HPV9 (Human Papilloma Virus vaccine) to my child (9 yrs & up):*

YESNO

HPV9 - (Human Papillomavirus Vaccine) VIS - https://tinyurl.com/4kyxyahk

Please administer Meningitis B vaccine to my child (Must be 16; required for entry into many colleges):*

YESNO

Meningococcal B VIS - https://tinyurl.com/48s94ur3

Please administer the Flu (Influenza) vaccine to my child (ages 6 months and up)

YESNO

Influenza VIS- https://tinyurl.com/542jvk2u

Please administer Covid-19 vaccine to my child (must meet health risk eligibility-a nurse at the clinic will discuss qualifying diagnoses with you)

YESNO

If you answered yes to the above question, please choose which brand of Covid-19 vaccine you would like your child to receive if eligible:

Moderna (ages 6 months and up)Pfizer (ages 5 and up)

Covid-19 VIS- https://tinyurl.com/ycxnbxnn

By signing below, I consent to the use and disclosure of my or my child’s personal health information for the purpose of health care operations, the entry of my or my child's immunization data into the statewide Children and Hoosiers Immunization Registry Program (CHIRP) database, along with the assignment of all payments from the insurer listed above to the Howard County Health Department for the services rendered. I also consent to the administration of all currently due school-required immunizations as well as the currently due ACIP recommended vaccinations marked "YES" above.

Signature of Parent or Guardian/ Patient if 18 or older:

Please print First and Last Name of Parent or Guardian/Patient if 18 years or older below:

Date Signed

MonthDayYear

Howard County Health Department

Insurance Information

Screening Questionnaire for Immunizations

Information about Immunizations being Offered