North DeKalb -Immunization Appointment

Immunization Appointment for
North DeKalb Health Center
(including 3231 and 3300 forms)
To schedule an Inmunization Appointment at North DeKalb Health Center please fill out the information below.

*For more than 3 Family Members an additional appointment form needs to be schedule

*Travel and I-693 online Appointment Scheduling coming soon*
Select an appointment date and time then click next*

BASIC INFORMATION
Are you scheduling an appointment for a family?*

YesNo
For how many family members you are scheduling the appointment?*

23
NOTE: For more than 5 family members ( patients) a new form needs to be filled out).

PATIENT INFORMATION AND INCOME DECLARATION
Do you need language assistance (interpreter)?*

YesNo
What language(s) do you speak?*
Please specify the language you speak
Patient Name 1 *

First NameMiddle NameLast Name
Date of birth (Patient 1)*

MonthDayYear
Date
Address*

Street Address

Street Address Line 2

CityState

Zip Code
Phone number*
Email address*
Emergency contact name*
Emergency contact phone number*
Format: (000) 000-0000.
Date of birth of emergency contact*

MonthDayYear
Date

FAMILY FORM
Patient Name 2*

First NameMiddle NameLast Name
Date of birth Patient 2*

MonthDayYear
Date
Sex Patient 2*

FemaleMale
Insurance ID number Patient 2
Patient Name 3

First NameMiddle NameLast Name
Date of birth Patient 3

MonthDayYear
Date
Sex Patient 3

FemaleMale
Insurance ID number Patient 3
If your family have Insurance please Upload the Images of Insurance Cards (No PDF)
Please upload all the Insurance ID cards for all the patients (FRONT and BACK)

Cancelof

STATEMENT OF ACCURACY OF INFORMATION PROVIDED:
I understand that I am responsible for full payment of Dekalb Public Health (DKPH) scheduled fees in cash, debit/credit card or a check from a Georgia Bank at the time of service unless I qualify for special discounted fees certain programs offer. Discounted fees are based on my income or my household's income and my number of dependents, which I have provided truthfully and accurately above.
Patient, Parent or Guardian Signature*
Date*

MonthDayYear
Consent for Release of Immunization Information into the Immunization Registry - GA Registry of Immunization Transactions & Services (GRITS)

DKPH is authorized to release any immunization information and/or documents containing such information to the GRITS database.
*

I agree to have immunization information released to GRITSI decline to have immunization information released to GRITS
Photography Consent: I consent for photographs to be taken of me or my child (or person for who I am the legal guardian). I understand that the information may be used in my medical record for the purposes of preventing identity theft. By consenting, I understand that I will not receive any payment. Refusal to consent will not affect the medical care I receive.
Patient, Parent or Guardian Signature*
Date*

MonthDayYear
*

I agree to have pictures taken of me or my child (or person for whom I am legal guardian).I decline to have pictures taken of me or my child (or person for whom I am legal guardian).
Additional comments:

CALL CENTER
Appointment Date Verification:

MonthDayYear
Date
Hour MinutesAM/PM Option
Approval Status*
Call Center Representative*
Date Entered into My Insight

MonthDayYear
Time Entered into MyInsight

Hour Minutes

AM/PM Option
Reschedule or Cancellation Reason
Original Date:

MonthDayYear
Date
Hour MinutesAM/PM Option
New Date:

MonthDayYear
Date
Hour MinutesAM/PM Option
Comments
FORM VERIFICATION

To review the form, click Back otherwise click Submit to book your appointment.
Should be Empty:

BASIC INFORMATION

PATIENT INFORMATION AND INCOME DECLARATION

PATIENT INFORMATION AND INCOME DECLARATION

INSURANCE INFORMATION:

FAMILY FORM

STATEMENT OF ACCURACY OF INFORMATION PROVIDED:

CALL CENTER

FORM VERIFICATION