School Vaccination Registration and Consent

In-School Physical and/or Vaccination Registration and Consent

Online HIPAA-compliant registration and consent form for parents/guardians completing in-school vaccination clinic paperwork remotely.
Student Information
School Currently Attended
Student Legal Name

First NameMiddle NameLast Name
Student Preferred Name

First NameMiddle NameLast Name
Date of Birth

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Current Grade in School
Race

Other
Ethnicity
Gender
Preferred Language
Is the student 18 years or older?
Has the student had a legal name change?
Previous Legal First Name
Previous Legal Last Name
Parent/Guardian Information
Parent/Guardian First Name
Parent/Guardian Last Name
Parent/Guardian Middle Initial
Relationship to Student
Parent/Guardian Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Parent/Guardian Alternate Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Parent/Guardian Email
example@example.com
Street Address
Apt Number
City
State
Zip
Physical Requested

If your child requires a physical, please submit the appointment request also.
What type of physical does the student need?
Vaccines Requested
Vaccines to be received at School Clinic
Please review the CDC Vaccine Information Statement (VIS) for any vaccine(s) you select above:
- Meningococcal/ACWY - https://www.cdc.gov/vaccines/hcp/current-vis/meningococcal-acwy.html
- HPV - https://www.cdc.gov/vaccines/hcp/current-vis/hpv.html
- Men B (Meningococcal B) - https://www.cdc.gov/vaccines/hcp/current-vis/meningococcal-b.html
- Tdap (Tetanus, Diptheria, Pertussis) - https://www.cdc.gov/vaccines/hcp/current-vis/tdap.html
- Polio - https://www.cdc.gov/vaccines/hcp/current-vis/polio.html
- MMR (Measles, Mumps, Rubella) - https://www.cdc.gov/vaccines/hcp/current-vis/mmr.html
- Varicella (Chickenpox) - https://www.cdc.gov/vaccines/hcp/current-vis/varicella.html
- Hepatitis A - https://www.cdc.gov/vaccines/hcp/current-vis/hepatitis-a.html
Would you like a Public Health Nurse to contact you to discuss any vaccines?
Question or concern for the Public Health Nurse
Insurance/Payment Information
Insurance Status
Medicaid DCN Number
Policy Holder Name

First NameMiddle NameLast Name
Relationship to Student
Policy Holder Date of Birth

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Policy Holder Address

Street Address

Street Address Line 2
CityState / ProvincePostal / Zip Code
Policy Holder Gender
Referral Number
DoD Number
Upload Insurance Card Front

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Upload Insurance Card Back

Cancelof
Insurance Company Name
Policy Number
Group Number
Policy Holder First Name
Policy Holder Last Name
Policy Holder Middle Initial
Policy Holder Address

Street Address

Street Address Line 2
CityState / ProvincePostal / Zip Code
Does the patient have any pending insurance coverage?
Would you like information on available coverage/resources?
Acknowledgements and Consents
I acknowledge that I have been provided access to the Vaccine Information Statement(s) (VIS) for the vaccine(s) selected and have reviewed the information, including benefits and possible risks.
Notice of Privacy Practices - Click on this hyperlink to view the Notice of Privacy Practices
I have been given an opportunity to read the “Notice of Privacy Practices” for the Southern Seven Health Department and to have any questions answered before signing below.
If signed by someone other than the patient, please indicate relationship to patient.:
I give permission for my child, listed on this registration form, to receive the vaccine(s) selected during the school vaccination clinic without a parent/guardian being physically present. I understand that all vaccine(s) will be administered by qualified healthcare professionals according to established medical guidelines. I understand that although serious reactions are rare, if my child experiences an unexpected or emergency reaction, I authorize the healthcare staff to provide appropriate assessment and treatment and/or seek emergency medical care if necessary. I understand that I may be contacted regarding my child's care as needed.
I give permission for my child, listed on this form, to receive the vaccine(s) selected during the school vaccination clinic without a parent/guardian being physically present.I understand that vaccines will be given by trained healthcare professionals following CDC-recommended guidelines and standard medical practices.I understand that vaccines, like all medical products, may cause side effects. Most are mild, such as soreness at the injection site or low fever. Serious reactions are rare but can occur.I understand that in the event of an allergic reaction or other medical emergency, clinic staff will provide appropriate care and may contact emergency medical services if needed. I authorize staff to take these actions if necessary for my child’s safety.I understand that I may be contacted about my child’s vaccination, side effects, or follow-up care if needed.
Electronic Signature
Upload ID (student or guardian ID)

Cancelof
Health Screening
Allergies to medications, food, vaccine component, or latex?
Allergy details and reaction description
Serious reaction to a vaccine in the past?
Details of prior vaccine reaction
Long-term health problems
Explanation
History of seizure or brain/nervous system problem?
Explanation
Immune-system problem
Explanation
Past 6 months: medications affecting immune system or radiation treatments?
Explanation
Past year: immune globulin, blood products, or antiviral drug?
Explanation
Vaccinations received in the last 4 weeks?
List all vaccines received
Is the child/teen pregnant?
How many weeks?
Has the child ever felt dizzy or faint before, during, or after a shot?
Is the child anxious about getting a shot(s)?
Should be Empty:

In-School Physical and/or Vaccination Registration and Consent

Student Information

Parent/Guardian Information

Physical Requested

Vaccines Requested

Insurance/Payment Information

Acknowledgements and Consents

Health Screening