Vaccine Registration | Countryside Public Health

Information about the Individual to Receive Vaccine

Clinic location:

Time Slot:

Last Name

First Name

Middle Name

Mother's Maiden Name (Last)

Date of Birth

Age

Address

Phone message - phone #:

City

State

Zip

County
Other:

Gender (M/F)

For children under 18, name of parent/guardian:

E-mail - address:

Text message - phone #:

Check yes or no to the following questions. If you answer yes to any of the questions or aren't sure how to answer a question, please fill in the "comments/questions" section below or contact Countryside Public Health

Payment Information - Please complete all that apply.

Choose Insurance
Medicare

Name exactly as it appears on your Medicare card:

Medicare #

Question	Yes	No
Do you have a Medicare Advantage Plan?
Do you have an Employer Health Plan?

Medical Assistance (MA) or PMAP

MA Card # (8 digits)

Do you have PMAP?
Yes
No

Do you have other health insurance?
Yes
No

Private/commercial health insurance

Insurance Company Name:

If other, fill in box below:

Policy Holder Name:

Policy Holder Birthdate:

Policy Holder Gender:

ID #:

Group #:

No health insurance

Question	Yes	No
I am interested in receiving Influenza Vaccine
I am interested in receiving the COVID-19 Vaccine or Booster
I am interested in receiving General Immunizations
Have you ever had a serious allergic reaction (difficulty breathing) or other problems after getting a flu vaccine such as hives?
Have you had a severe reaction to eggs or components of the flu vaccine such as gelatin?
Have you ever had Guillain-Barre Syndrome?
Would you prefer receiving FluMist (intranasal flu vaccine), if vaccine is available?
For a child age 2 through 4 years, in the past 12 months, has a healthcare provider told you the child had wheezing or asthma?
Do you have a long-term health problem with heart disease, lung disease (including asthma), kidney disease, neurologic disease, liver disease, or metabolic disease (e.g. diabetes)?
Does the person to be vaccinated have a) an open channel between the cerebrospinal fluid (CSF) and the mouth, throat, nose or ear or any other cranial CSF leak, or b) a cochlear implant, or c) an immunocompromising condition due to any cause (e.g., medication, congenital or acquired immunodeficiency, HIV infection, or a missing or non-functioning spleen [e.g., caused by sickle cell disease])?
Is the person to be vaccinated currently taking influenza antiviral medications, or have they taken any within the past 3 weeks?
For a child or teen 6 months through 17 years, are they receiving aspirin- or salicylate-containing medicine?
Are you pregnant or could you become pregnant within the next month?
Do you live with or expect to have close contact with a person whose immune system is severely compromised and who must be in protective isolation (e.g. an isolation room of a bone marrow transplant unit)?
Have you received any other vaccinations in the past 4 weeks?
Additional Comments/Questions:

Vaccine Registration | Countryside Public Health

Editable Region

Payment Information - Please complete all that apply.