Patient Vaccine Clinic Consent Form

Is this your first, second or booster dose? *

Choose a vaccine type to determine your clinic choices: *

Choose your preferred Location:

Choose a Clinic to Register for: *

Are you a State Employee ? *

Last Name: *

First Name: *

Middle Name: *

Suffix:

Date of Birth: *

Gender at Birth: *

Telephone: *

Email: *

Street Number: *	Street Name: *	PO Box:	Apartment:

City: *	State: *	County: *	Zip: *
	ALABAMA ALASKA ARIZONA ARKANSAS CALIFORNIA COLORADO CONNECTICUT DELAWARE DISTRICT OF COLUMBIA FLORIDA GEORGIA (US) HAWAII IDAHO ILLINOIS INDIANA IOWA KANSAS KENTUCKY LOUISIANA MAINE MARYLAND MASSACHUSETTS MICHIGAN MINNESOTA MISSISSIPPI MISSOURI MONTANA NEBRASKA NEVADA NEW HAMPSHIRE NEW JERSEY NEW MEXICO NEW YORK NORTH CAROLINA NORTH DAKOTA OHIO OKLAHOMA OREGON PENNSYLVANIA PUERTO RICO RHODE ISLAND SOUTH CAROLINA SOUTH DAKOTA TENNESSEE TEXAS U.S. VIRGIN ISLANDS UTAH VERMONT VIRGINIA WASHINGTON WEST VIRGINIA WISCONSIN WYOMING	ALLEN ANDERSON ATCHISON BARBER BARTON BOURBON BROWN BUTLER CHASE CHAUTAUQUA CHEROKEE CHEYENNE CLARK CLAY CLOUD COFFEY COMMANCHE COWLEY CRAWFORD DECATUR DICKINSON DONIPHAN DOUGLAS EDWARDS ELK ELLIS ELLSWORTH FINNEY FORD FRANKLIN GEARY GOVE GRAHAM GRANT GRAY GREELEY GREELEY GREENWOOD HAMILTON HARPER HARVEY HASKELL HODGEMAN JACKSON JEFFERSON JEWELL JOHNSON KEARNY KINGMAN KIOWA LABETTE LANE LEAVENWORTH LINCOLN LINN LOGAN LYON MARION MARSHALL MCPHERSON MEADE MIAMI MITCHELL MONTGOMERY MORRIS MORTON NEMAHA NEOSHO NESS NORTON OSAGE OSBORNE OTTAWA OUT OF STATE PAWNEE PHILLIPS POTTAWATOMIE PRATT RAWLINS RENO REPUBLIC RICE RILEY ROOKS RUSH RUSSELL SALINE SCOTT SEDGWICK SEWARD SHAWNEE SHERIDAN SHERMAN SMITH STAFFORD STANTON STEVENS SUMNER THOMAS TREGO WABAUNSEE WALLACE WASHINGTON WICHITA WILSON WOODSON WYANDOTTE

Insurance Provider: *	Ethnicity: *	Race: *	Additional Races (Up to four):

** ALL QUESTIONS ARE REQUIRED. PLEASE PROVIDE YOUR RESPONSE **

Select Time Slot: *

I have been offered a copy of the relevant Vaccine Information Sheet (VIS). I have read, had explained to me, and understand the information in the VIS.

Signature of Patient *

Date *

Printed Name of Patient *

Date of Birth *

SUCCESS

You can use the Confirmation Number for reference to look up your information.

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Click Lookup Information to view the submitted request.

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If you would like to submit a new request, Please click Submit a New Request.