JASPER COUNTY HEALTH DEPPARTMENT
IN COOPERATION WITH
THE DEPARTMENT OF HEALTH OF MISSOURI
105 LINCOLN – CARTHAGE, MISSOURI 64836
PHONE: (417) 358-3111 – FAX: (417) 358-0494
Please check boxes below, fill out the consent form and return to front desk.
Do you have: Health Insurance? Yes _____ No _____
Does your Insurance pay for shots? Yes _____ No _____
Do you have: Medicaid? Yes _____ No _____ DCN:____________
Are you: American Indian? Yes _____ No _____
Alaskan? Yes _____ No _____
LAST NAME FIRST NAME MIDDLE INITIAL | SEX MALE FEMALE | BIRTHDATE | ||
PHONE NUMBER | RACE WHITE ASIAN OR PACIFIC ISLANDER INDIAN OTHER UNKNOWN AFRICAN AMERICAN/BLACK | ETINICITY NON - HISPANIC CUBAN UNKNOWN MEXICAN CENTRAL/SOUTH AMERICAN PUERTO RICANO OTHER | ||
STREET ADDRESS CITY STATE ZIP CODE | ||||
YES ____ YES ____
NO ___ Has your child ever had a reaction to the Pertussis component of the DTP vaccine? NO ___ Has your child ever had an injury or accident within the last 10 yrs and received a tetanus shot? If yes, what was the date? ____/____/_____
I hereby give permission for the Health Nurse to immunize my child, and after reading the information sheet I am aware of possible reactions from the shot. I also understand that the HIPAA Privacy Policy is available for review at the Jasper County Health Department.
_________________________________________________ DATE: ____________ SIGNATURE OF PERSON AUTHORIZED TO MAKE THE REQUEST
FOR CLINIC USE ONLY
Tdap | MCV4 | Td |
CLINIC ID JASPER COUNTY HEALTH DEPT | CLINIC ID JASPER COUNTY HEALTH DEPT | CLINIC ID JASPER COUNTY HEALTH DEPT |
Date Vaccinated | Date Vaccinated | Date Vaccinated |
Manuf. & Lot # | Manuf. & Lot # | Manuf. & Lot # |
Signature/Vacc Admin | Signature/Vacc Admin | Signature/Vacc Admin |
L or R Deltoid | L or R Deltoid | L or R Deltoid |