2026-2027 Employee Vaccine Clinic Consent (Public Schools)

Employee Vaccine Clinic Consent (Public Schools) 2026-2027

Patient Registration Form
Employee's Legal Last Name
Employee's Legal First Name
Employee's Date of Birth

MonthDayYear
2 digit month, 2 digit day, 4 digit year
Employee's Primary Language
Employee's Address

Street Address

Street Address Line 2

CityState

Zip Code
Employee's Race
Employee's Ethnicity
Employee's Gender at Birth
Employee's Marital Status
Employee's Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Employee's Email
example@example.com
Place of Employment
Does the employee have health Insurance and/or Medicaid?
What is the name of the health Insurance/Medicaid provider?
:
What is the last name of the insurance policy holder?
Type the last name.
What is the first name of the insurance policy holder?
Type the first name.
How is the policy holder related to the patient?
What is the birth date of the policy holder?

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
What is the gender of the policy holder?
What is the address of the insurance policy holder?

Street Address

Street Address Line 2

CityState

Zip Code
What is the insurance policy holder's phone number?
Please enter a valid phone number.Format: (000) 000-0000.
What is the Member ID Number/Subscriber Number?
For Tricare, use benefits number on back of CAC card.
What is the Group Number?
Attach a photo or scanned copy of the FRONT of the health insurance card.

Cancelof
Attach a photo or scanned copy of the BACK of the health insurance card.

Cancelof
General consent for treatment

By signing below, I hereby authorize the County Health Department to render the appropriate services and presumptive treatment to me at my request. I understand that to render care, the staff may need to examine, conduct tests or diagnositc procedures, administer medicines or treatments. I understand that I will have an opportunity to ask my healthcare provider questions regarding such care and read any informational materials given to me as deemed appropriate. I acknowledge that all of the information I have provided to the County Health Department staff is true and accurate to the best of my knowledge.

Vaccine(s) given to me will be administered by a licensed nurse. I understand that the vaccine(s) received are recommended by the Center for Disease Control (CDC) for the prevention of the disease indicated.
Signature
I (please check all boxes that apply):
If the answer to any of the above allergy/reaction questions is YES, please list and explain below.
Signature
North Central Health District Notice of Privacy Practices

Acknowledgement of Receipt of Notice of Privacy Practices

I acknowledge that I have reviewed and understand the Notice of Privacy Practices for the North Central Health District. The Notice sets forth the ways in which my personal health information may be used or disclosed by the North Central Health District or the County Health Department and outlines my rights with respect to such information.
Signature
Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Should be Empty:

Employee Vaccine Clinic Consent (Public Schools) 2026-2027