Licking Heights Student Immunization Sign-Up
Hi Parents and Students of Licking Heights,

Please fill in the form below to sign up for student immunization.

Our Student Immunization Clinic will be on Thursday, August 11th from 4:30pm to 6:30pm. We will be offering Tdap and Meningicoccal vaccines as recommended by the CDC and school requirements.

We are collecting your insurance information to pre-verify your coverage and any cost prior to the clinic.

Students under the age of 13 will require a prescription to be vaccinated.

Students under the age of 18 will require a parent to be present during immunization.

Thank you and we look forward to seeing you at our Student Immunization Clinic!


Jessica Cline, PharmD, RPh, BCACP
Meijer Clinical Pharmaicst

and

Peggy Auer, RN
Licking Heights School District Nurse
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What is the student's full name? *
What is the student's date of birth? *
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/
DD
/
YYYY
What is the best phone number to contact the parent of the student?
What immunizations does the student intend to receive? *
Required
Example Insurance Cards
What is the student's pharmacy benefits insurance company? *
What is the RxBin on the student's insurance card? *
What is the PCN on the student's insurance card? *
What is the ID# on the student's insurance card? *
What is the RxGroup on the student's insurance card? *
If you have questions or comments, please enter them here. Thanks!
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