School health needs tool
Helps you find out if we can help you with your physical and vaccination needs for school.
* Required
Email address
*
Child’s first name and age
*
Parent’s first name
*
Phone number
*
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
List vaccines needed
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.
Send me a copy of my responses.
Submit
Never submit passwords through Google Forms.
reCAPTCHA
Privacy
Terms
This content is neither created nor endorsed by Google. -
Terms of Service
Forms
