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  • Vax Fax Pre-Registration Form

  • Which Vax Fax immunization event are you planning on attending?*
  • Would you like to receive a vaccine at the event(s), if eligible?*
  • Which vaccine(s) are you interested in receiving?*

  • Patient Information

  • Today's Date*
     - -
  • Patient Date of Birth*
     - -
  • Format: (000) 000-0000.
  • Format: (000) 000-0000.
  • Sex*
  • Race*
  • Ethnicity*
  • Any patient allergies?*

  • Insurance Information

    If you would like to be vaccinated
  • Insurance Information*

  • Private Insurance Information

  • Format: (000) 000-0000.
  • Policy Holder Date of Birth
     - -
  • Format: (000) 000-0000.

  • Authorization and Consent

  • Personal Financial Responsibility: By signing this form, and in return for the services rendered by the Platte County Health Department (PCHD), I am personally responsible for all fees not paid by any third party on my behalf.


    Assignment of Insurance Benefits: I hereby assign all my interest and rights to all insurance benefits otherwise payable to me from any policy to PCHD. I agree that PCHD may disclose any portion of my medical, financial, or personal information to any person or organization requiring such information as a condition of paying, receiving payment for, or justifying payment for my health care or the health care of one for whom I am responsible. I further authorize payment of all insurance benefits, otherwise payable to me, for all treatment provided directly to PCHD. I understand that I am responsible for any amount not covered by insurance.


    My signature indicates that I have reviewed a copy of the “Notices of Privacy Practices” and have read the Emergency Use Authorization (EUA) Fact Sheet for REcipients/Caregivers and/or the Vaccine Information Statement (VIS) for the vaccine(s) that I am requesting be given to the person named on the form.

  • Date Signed*
     - -

  • Screening Checklist for Contraindications to Vaccines for Patients

  • For Self/Parents/Guardians: The following questions will help us determine which vaccines you or your child may be given today. If you answer "yes" to any question, it does not necessarily mean an individual should not be vaccinated. It just means additional questions must be asked. If a question is not clear, please ask your healthcare provider to explain it.

  • Is the patient sick today?*
  • Does the patient have allergies to medications, food, a vaccine component, or latex?*
  • Has the patient had a serious reaction to a vaccine in the past?*
  • Does the patient have a long-term health problem with lung, heart, kidney, or metabolic disease (e.g., diabetes), asthma, a blood disorder, no spleen, complement component deficiency, a cochlear implant, or a spinal fluid leak? Is he/she on long-term aspirin therapy?*
  • Has the patient, a sibling, or a parent had a seizure; has the patient had brain or other nervous system problems?*
  • Does the patient have cancer, leukemia, HIV/AIDS, or any other immune system problems?*
  • Does the patient have a parent, brother, or sister with an immune system problem?*
  • In the past three months, has the patient taken medications that affect the immune system such as prednisone, other steroids, or anticancer drugs; drugs for the treatment of rheumatoid arthritis, Crohn's disease, or psoriasis; or had radiation treatment?*
  • In the past year, has the patient received a transfusion of blood or blood products, or been given immune (gamma) globulin or an antiviral drug?*
  • Has the patient received vaccinations in the past 4 weeks?*
  • Has the patient ever fainted during needle stick (shots, blood draws, finger sticks) procedures?*
  • Has the patient ever had Guillain-Barre Syndrome?*
  • For Females Only: Is the patient pregnant or is there a chance she could become pregnant during the next month?*
  • For Children Only: If the child to be vaccinated is two through four years of age, has a healthcare provider told you that the child has wheezing or asthma in the past twelve months?*
  • For Children Only: If your child is a baby, have you ever been told that he or she has had intussusception?*

  • By signing this statement, I hereby authorize the Platte County Health Department to disclose the immunization records to the daycares, schools, or clinics that partake in the care of myself or child of which I am the legal guardian for. I understand that these records will be used to determine wheter or not my child is compliant with state laws and to assist clinicians with determining what other vaccinations myself or my child may need.

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