Warren and Madison County Only 26-27 Back to School Immunization Appointment and Consent Form

Back to School Immunization Appointment Scheduler
Immunizations will be provided at the Warren County Health Services office:

301 N. Buxton St., Ste. 202 Indianola, IA 50125

515-690-9190
Patient Name

First NameLast Name
Patient Birthdate

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Patient Race:

Other
Ethnicity Race:
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Parent/Guardian Name:
Phone Number
Please enter a valid phone number we can reach you at if we have any questions.Format: (000) 000-0000.
Parent/Guardian Email:
School District
Must be attending school in either Madison or Warren Counties
Immunizations Needed:
Appointment
Insurance Information
Please either upload the front and back of your insurance card or enter the appropriate card information below.

If you choose not insured, American Indian/Alaskan Native, or Underinsured, your child qualifies for the VFC program and no payment is required.

Please note, we are NOT in network with Health Partners Insurance, you may be responsible for the cost of any vaccines administered. If you have insurance questions, please call us at 515-690-9190.
Does your child have insurance that covers vaccines?
Vaccines for Children (VFC) Program Eligibility:
Medicaid/MCO Number:
Please upload the front of your insurance card

Cancelof
Please upload the back of your insurance card

Cancelof
Insurance Company:
Ex: Wellmark, United Healthcare
Member ID:
Group #:
Card Holder Name:
Card Holder DOB:
Relationship to Patient:
Health Screening Questions

For patients to be vaccinated: The following questions will help us determine if there is any contraindications to vaccination today. If you answer "Yes" to any question, it does not necessarily mean your child 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.

Rows	Yes	No	Unsure
Is the person being vaccinated sick today or have a fever?
Does the person being vaccinated have an allergy to a component of the vaccine?
Has the person being vaccinated ever had a serious reaction to any vaccine in the past?
Has the person being vaccinated ever had Guillain-Barre Syndrome?
Is the person to be vaccinated anxious about getting a shot today?

Vaccine Information Statements (VIS)

Please click the link to review VIS for all vaccines you selected to receive.
DTaP: https://www.immunize.org/wp-content/uploads/vis/dtap.pdf

Polio: https://www.immunize.org/wp-content/uploads/vis/polio_ipv.pdf

Measles, Mumps, Rubella, Varicella: https://www.immunize.org/vaccines/vis/mmrv/

Tdap: https://www.immunize.org/wp-content/uploads/vis/tdap.pdf

MCV4: https://www.immunize.org/vaccines/vis/menacwy/

Hepatitis B: https://www.immunize.org/vaccines/vis/hepb/
Consent for Vaccination:

I have read, or have had explained to me, the information about the vaccine(s) being administered today. I have had a chance to ask questions which were answered to my satisfaction. I believe I understand the benefits and risks of vaccination and request vaccination to be administered to me, or the above named for whom I am authorized to make this request.

I understand that under the Health Insurance Portability & Accountability Act of 1996 (HIPPA) I have certain right to privacy regarding my protected health information. The Notice of Privacy Practice has been made available to me, which explains these rights. Warren County Health Services Notice of Privacy Practice can be viewed online at: https://healthservices.warrencountyia.org/Policy_HIPAA.pdf

I authorize the release of medical or other information necessary to process billing claims. I authorize Payer to pay provider directly and agree to pay any co-pay, deductible, or amount not paid by insurance.
Form completed by

First NameLast Name
Signature of Patient (or Parent/Guardian of person less than 18 years old)

Patient is person receiving immunization
Should be Empty:

Back to School Immunization Appointment Scheduler

Insurance Information

Health Screening Questions

Vaccine Information Statements (VIS)