Family Member Registration Form

Howard County Health Department

Family Member Registration Form-Flu and/or Covid vaccine
Name of Person to be Vaccinated*

First NameMiddle NameLast Name
Date of Birth*

MonthDayYear
Age*
Legal Gender*
Mobile Phone Number*
Email*
example@example.com
Home Address*

Street Address

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

CityState

Zip Code
Race*
Ethnicity*
Language*
Insurance Information
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
Screening Questionnaire for Immunizations
1.) Is the person to be vaccinated sick today?
2.) Has the person receiving immunizations had a serious reaction to a vaccine in the past?
3.) Does the person have allergies to medications, foods, a vaccine component, or latex?
If YES, please list allergies and reactions:
4.) Does the person 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 person on long-term aspirin therapy?
If you answered yes to the above question, please list your health condition(s):
5. Has the person to be vaccinated ever had Guillain-Barre' syndrome?
Information about Immunizations being Offered
I would like to receive the flu vaccine today

YESNO
I would like to receive the Covid-19 vaccine today*

YESNO
If you answered yes to receive a Covid vaccine, please choose the brand you would like to receive

ModernaPfizer
Below are the links to the respective Vaccine Information Statements (VIS):
- Influenza (6 months and up)-https://tinyurl.com/4pd8h35z
- Covid-19 (6 months and up)-https://tinyurl.com/5ekwyhkn
*If you are registering to receive a Covid-19 vaccine and are under the age of 65, a registered nurse from the Howard County Health Department will review your underlying health conditions with you to assess eligibility to receive the Covid vaccine according to the new CDC guidelines.

Please note: Programs are available for children and adults without health insurance to provide immunizations at no cost during this event. Please call the Health Department with any questions you may have. (765) 456-2408, option #1.
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 immunizations that i have given written consent to receive for myself or my child.
Signature of Parent or Guardian/ Patient if 18 or older:

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Date Signed

MonthDayYear
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Howard County Health Department

Insurance Information

Screening Questionnaire for Immunizations

Information about Immunizations being Offered