MMR Immunization Clinic

Howard County Health Department

MMR Immunization Clinic
Name of Person to be Vaccinated

First NameMiddle NameLast Name
Has the person to be vaccinated ever went by a different last name? If yes, please list below
Date of Birth

MonthDayYear
Age
Legal Gender
Mobile Phone Number
Format: (000) 000-0000.
Email
example@example.com
Physician/Medical Provider Name
Home Address

Street Address

Street Address Line 2 (Apt #, Suite #, etc.)

CityState

Zip Code
Race
Ethnicity
Language
Insurance Information
Does the person receiving vaccinations have health insurance?
Primary Insurance Name
i.e. Anthem, Cigna, United Healthcare. Medicaid, Medicare
Member ID # - Primary Insurance
Insured Name - Primary Insurance
Insured Date of Birth
Secondary Insurance Name
This information is REQUIRED if client has additional insurance
Member ID# - Secondary Insurance
This information is REQUIRED if client has additional insurance
Insured Name - Secondary insurance
This information is REQUIRED if client has additional insurance
Insured Date of Birth
This information is REQUIRED if client has additional insurance
Please choose which date you plan to attend the MMR vaccine clinic. Both clinic times are 8:30 a.m. to 3:30 p.m.
Please note: if you find you are unable to attend the date you choose on this registration form, you may attend the other date.
Screening Questionnaire for Immunizations
Are you sick today?
2.) Do you have long-term health problems with heart disease, lung disease, asthma, kidney disease, metabolic disease (e.g. diabetes), anemia, or other blood disorder?
3.) Have you received a transfusion of blood or blood products, or been given a medicine called immune (gamma) globulin or an antiviral drug in the last year?
If YES, please list the blood product or medication given and the date:
4.) Do you have allergies to medications, foods, a vaccine component, or latex?
If YES, please list allergies and reactions:
5.) Have you had a seizure, brain, or other nervous system problem?
6.) Have you taken cortisone, prednisone, other steroids, or anticancer drugs, or had radiation treatments in the past 3 months?
7.) Have you ever had a serious reaction after receiving a vaccination?
If yes, please describe the reaction and to which vaccine.
8.) Are you pregnant, or is there a chance you could become pregnant during the next month?
9.) Have you received vaccinations in the last 4 weeks?
If YES, please list the vaccinations given and on what date:
13.) Do you smoke or vape?
Information about the Immunization being Offered
Prior to the clinic, the state immunization registry (CHIRP) will be reviewed by a Health Department nurse to assess each participant’s vaccination history and the need for a MMR vaccine.

If you do not have a CHIRP record, (i.e. you moved to Indiana from another state) but you do have a shot record, please email it to: kelly.carpenter@howardcountyin.gov or you may fax it to (765) 456-7000 attention to Kelly Carpenter. This will enable staff time to evaluate your shot record prior to the clinic.

The following is a link to the Vaccine Information Statement for the MMR vaccine.
- MMR - https://tinyurl.com/ykwbctwz
By signing below, I consent to the use and disclosure of my health information for healthcare operations, including the entry of my immunization records into the Indiana CHIRP database. I authorize all insurance payments for services rendered to be assigned to the Howard County Health Department. I also consent to the administration of the MMR vaccine to which I have agreed.
Signature of Patient
Please print First and Last Name of Patient below:
Date Signed

MonthDayYear
Should be Empty:

Howard County Health Department

Insurance Information

Screening Questionnaire for Immunizations

Information about the Immunization being Offered