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* 1. Patient Name

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* 2. Patient Date of Birth

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* 3. Patient Age

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* 4. Phone Number

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* 5. Parent/Guardian Name

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* 6. Address

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* 7. Patient Gender

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* 8. Patient Race (select all that apply)

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* 9. Patient Ethnicity

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* 10. What school does your child attend?

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* 11. Do you have Medicaid or another private healthcare insurance?

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* 12. Name of health insurance

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* 13. Health insurance policy number

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* 14. Group number

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* 15. Has the person to be vaccinated been sick recently?

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* 16. Does the person to be vaccinated have allergies to medications, food, a
vaccine component, or latex?

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* 17. Has the person to be vaccinated ever had a serious reaction to a vaccine in the past?

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* 18. Does the person to be vaccinated have a long-term health problem with heart disease, lung disease, asthma, kidney disease, metabolic disease (e.g. diabetes), anemia, or other blood disorders?

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* 19. Does the person to be vaccinated have cancer, leukemia, HIV/AIDS, or any other immune system problem?

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* 20. In the past 3 months, has the person to be vaccinated taken any medications that affect their immune system, such as prednisone, other steroids, or anticancer drugs; drugs for the treatment of rheumatoid arthritis, Crohn's disease, or psoriasis, or had radiation treatments?

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* 21. Has the person to be vaccinated had a seizure, brain, or other nervous system problems (such as Guillain-Barre syndrome)?

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* 22. During the past year, has the person to be vaccinated received a blood transfusion or blood products, immune globulin, antiviral drug, and/or treatment for COVID-19 ?

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* 23. For women: Is the person to be vaccinated pregnant or is there a chance that they could become pregnant during the next month?

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* 24. Has the person to be vaccinated received any vaccinations in the past month?

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* 25. If the person to be vaccinated is a baby, have they ever had intussusception?

Financial Policy Acknowledgement

By signing this consent, I acknowledge that I understand and agree to the financial policy at WCHD. I also request payment of government benefits and/or health insurance to the Williams County Health Department.

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* 26. I agree to the financial policy at WCHD

HIPAA Acknowledgement

By signing this consent, I acknowledge that I have received the notice of privacy practices. I authorize the use and/or disclosure of my health information for treatment, payment, or health care operations. I have the right to not sign this consent; however, if I refuse to sign this consent, the health department has the right to refuse treatment to me. My rights include (1)to receive a paper copy of the Notice of Privacy Practices prior to signing consent. (2) to request restrictions on the use and disclosure of health information. (3) the right to revoke the consent at any time except to the extent that the health department has already taken certain actions based on the consent prior to revoking it. (4) the right to receive a copy of this consent form after signing it. This consent is effective unless and until I revoke it in writing

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* 27. I have received notice of privacy practices from WCHD.

Immunization Consent

I have received a copy and have read or have had read to me and explained the information contained in the Vaccine Information Statement. I have had a chance to ask questions which were answered to my satisfaction. I understand the benefits and risks of the vaccine and I authorize that the vaccine be given to me or the minor for whom I am authorized to make this request.

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* 28. I have received and read the immunization consent

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* 29. In order to complete this form, please type your full name into the box below. Typing your name indicates your signature and agreement with the provisions contained herein. I certify that all information contained herein is true and accurate.

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* 30. Enter today's date

Date
Insurance Card

Please upload a photo of the front and back of your medical insurance card below.

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* 31. Please upload a photo of the front of your medical insurance card.

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* 32. Please upload a photo of the back of your medical insurance card.

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