TVFC Screening
Do you have health insurance that covers these vaccines?*field type radio button
Do you have health insurance that covers these vaccines?YesNo
Do you have Medicaid?*field type radio button
Do you have Medicaid?YesNo
Does your child participate in CHIP?*field type radio button
Does your child participate in CHIP?YesNo
Is your child American Indian or Alaskan native?*field type radio button
Is your child American Indian or Alaskan native?YesNo
Health Screening/Consent
Are you sick today or have you had a fever in the past 48 hours?*field type radio button
Are you sick today or have you had a fever in the past 48 hours?YesNo
Do you have any allergies?*field type radio button
Do you have any allergies?YesNo
List all medicine or vaccine allergies*field type multi line
I am giving permission to the vaccinator to provide a copy of my vaccine record (consent) to my child’s campus and the state registry system.*field type radio button
I am giving permission to the vaccinator to provide a copy of my vaccine record (consent) to my child’s campus and the state registry system.YesNo

Patient Last Name*field type single line
Input blocked. Maximum character limit of 4000 characters reached.
Patient First Name*field type single line
Input blocked. Maximum character limit of 4000 characters reached.
Patient Middle Initialfield type single line
Input blocked. Maximum character limit of 4000 characters reached.
Birth Date*field type date
Agefield type single line
Input blocked. Maximum character limit of 4000 characters reached.
Sexfield type single line
Input blocked. Maximum character limit of 4000 characters reached.
Street Address*field type single line
Input blocked. Maximum character limit of 4000 characters reached.
City*field type single line
Input blocked. Maximum character limit of 4000 characters reached.
State*field type drop-down
Zip*field type single line
Input blocked. Maximum character limit of 4000 characters reached.
County*field type single line
Input blocked. Maximum character limit of 4000 characters reached.
Phone Number*field type single line
Input blocked. Maximum character limit of 4000 characters reached.
Email*field type email
Emergency Contact Personfield type single line
Input blocked. Maximum character limit of 4000 characters reached.
Emergency Contact Phone Numberfield type single line
Input blocked. Maximum character limit of 4000 characters reached.
Patient or Guardian Signature*field type signature
Submitted_Datefield type single line
Input blocked. Maximum character limit of 4000 characters reached.

Patient Information & Consent