SBHC Vaccination Appointment Request

***Please complete one submission per student***

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* 1. Please Select Your Preferred Location

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* 2. What Time of Day Would You Like The Appointment to Be?

Morning (8am - 11:30am)

Afternoon (12pm - 4:30pm)

No Preference

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* 3. Student Information

Student's First Name

Student's Last Name

Student's Date of Birth

Student's Mailing Address

City/Town

State/Province

ZIP/Postal Code

Student's Insurance Provider (please enter "N/A' if student is uninsured)

Is the student covered by Medicaid? (Please enter 'Yes, No, or Unsure')

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* 4. (Parent/Guardian Contact Information) ***Please re enter your contact information if you are a student who is emancipated or 18+ completing this survey independently.

Consenting Parent/Guardian Full Name (FIRST/LAST)

Consenting Parent/Guardian Email Address

Consenting Parent/Guardian's phone number

Phone Number for Alternate Contact (please enter 'N/A' if not available)

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* 5. Which Vaccines Does Your Student Currently Need?

Unsure

Diphtheria/Tetanus/Pertussis (DTaP)

Polio (IPV)

Varicella (if no History of chicken Pox)

Measles/Mumps/Rubella (MMR)

Hepatitis B

Hepatitis A

Hib (Haemophilus Influenza Type B)

PCV (Pneumococcal)

Flu

COVID-19 (Pfizer - Ages 12 & Up)

Tdap

Meningococcal (Men ACWY)

Human Papillomavirus Vaccine (HPV)

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* 6. If you selected the COVID-19 vaccination, which dose is your student need of? (If you DID NOT select the COVID-19 vaccine in question 5 please skip this question)

1st Dose

2nd Dose

Unsure

Thank you for expressing your interest in visiting one of the District of Columbia’s School Based Health Centers. Once this form is completed, please allow for up to 72 business hours for response. When contacted, the selected School Based Health Center Staff will provide to you the next available appointment time/date. Please be sure to click on done to ensure your answers have been saved and properly submitted.