Self-referral Measles Exposure

Self-referral Measles Exposure

Fill the Self-referral Measles Exposure form if you were exposed to Measles. If you have any questions, please contact Lewis and Clark Public Health at 406-457-8900.
Name*

First NameLast Name
Date of Birth *

MonthDayYear
Date
Address*
Phone Number*
Please enter a valid phone number.
Email (Optional)
example@example.com
When were you exposed? *

MonthDayYear
Date
How did you get exposed?*

Friend/Family/Co-Worker, etc.Public Exposure (i.e. restaurant, store)Unknown/Other
Please provide where:
Target, Wal-mart, Suds, etc.
Please specify:
Are you Immune to Measles? (Select one and follow the recommendations below)*

I was vaccinated with Measles vaccine before 1968. You are not considered immune without proof of the type of MMR vaccine you received.I have verified my MMR with an immunization record or with a healthcare providerI think I have had an MMR vaccine but I do not have a recordI was born before 1957I have not had an MMR VaccineUnknown
Are you having Symptoms?

YesNo
Vaccines given between 1957-1967 may not have provided long-term protection.

The recommendation is for you to stay home and away from others for 21 days from exposure.

If symptoms occur call your healthcare provider and arrange testing. Call ahead before going in.
The recommendation is for you to stay home and away from others for 21 days from exposure.

If symptoms occur call your healthcare provider and arrange testing. Call ahead before going in.
Stay home and call your healthcare provider and arrange testing. Call ahead before going in.
No need to stay home and away from others, but watch for symptoms for the next 21 days.

If symptoms develop, then stay home and away from others and call your healthcare provider. Call ahead before going in.
Ways to find your record:
- Check your patient portal
- Call your healthcare provider (out of state, local, past, and/or current)
- Call the school nurse
- Check out of state immunization registries
- Check Military record
- Check employment record
- Fill out this ROI link so we can check the Montana State immunization registry. We will look up your record and send it to you within 3 business days.
Until you know that you have an MMR vaccine, the recommendation is to stay home and away from others for 21 days from exposure.

If symptoms occur call your healthcare provider and arrange testing. Call ahead before going in.
Symptoms to watch for:
- Fever
- Cough
- Sneezing
- Runny Nose
- Red, Watery Eyes
- Spots in the Mouth
- Rash
After filling out this form, do you still want to speak to a public health staff?*

YesNo
Please specify your question(s) or request(s) you may have:
Please allow 5-7 business days to speak with a public health staff. If you need to speak to someone sooner, please contact your healthcare provider.
Please allow 5 business days to speak with a public health staff. If you need to speak to someone sooner please contact your healthcare provider.
Should be Empty:

Self-referral Measles Exposure

Symptoms to watch for: