School health needs tool
Helps you find out if we can help you with your physical and vaccination needs for school.
* Required
Email address
*
Your email
Child’s first name and age
*
Your answer
Parent’s first name
*
Your answer
Phone number
*
Your answer
Do you need a physical form?
*
Yes
No
Maybe
Do you need vaccinations?
*
Yes
No
Maybe
Do you know which vaccines are needed?
Yes
No
Maybe
Clear selection
List vaccines needed
Your answer
Do you need assistance determining what vaccines your child needs?
Yes
No
Maybe
Insurance coverage?
*
Straight Medicaid - Policy #
Medicaid managed care
Child health plus
Insurance from my employer or other parent's employer
None
I have insurance, not sure which.
Native American/Pacific Islander/Native Alaskan
Other:
Optional insurance card numbers to determine what type, please provide all numbers and labels to help us help you.
Your answer
Send me a copy of my responses.
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