Patient Information & Consent

  • TVFC Screening

  • Do you have health insurance that covers these vaccines?
  • Do you have Medicaid?
  • Does your child participate in CHIP?
  • Is your child American Indian or Alaskan native?
  • Health Screening/Consent

  • Are you sick today or have you had a fever in the past 48 hours?
  • Do you have any allergies?
  • 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.
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