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East Valley Vaccination and Examination Center

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Text Box: Confidential For Office Staff Use Only Patient Registration Date______________________ Date of Birth____________________________ Legal Patient Name_______________________________________________________________ _______________________ Last Name First Middle Initial Preferred Name to be Called Address____________________________________________________________________________________________________ Street City State Zip Mother’s Maiden Name or Guardian’s Name ______________________________Phone #s (H)_________________________ Vaccine Record Information (please initial on the line) (C)__________________________ ___________ I agree to allow the health care provider giving vaccinations to release information about all vaccinations given to me, or to the person for whom I am authorized to consent, to the Arizona State Immunization Information System (ASIIS), other health care providers and schools in order to avoid receiving unnecessary vaccinations and to provide information about what immunizations have been received. I understand that I am not required to agree to the release of this information in order to receive the vaccinations I request. Certification (please mark appropriate box) I certify that I do NOT have Medicare insurance I certify that I do have Medicare insurance Allergy ALERT: yes no Current Medications To the best of my knowledge, the above information is complete and correct. I understand that it is my responsibility to inform my healthcare provider if I, or my minor child, ever have a change in health. _____________________________________________ ________________ Signature of Patient, Parent Guardian or Personal Representative Date ________________________________________________________ ____________________ Please print name of Patient, Parent, Guardian, or Personal Representative Relationship to Patient How did You Hear About Us? ___ Internet ___phonebook ___ friends/family ___Doctor ___travel agent ___ school ___flier/publication ___Work ___Church ___Other (please list) ____________________________________ Travel Patients Only: Date of Travel ___________ Length of Travel _______________ Destination & Country _______________________

Initials

ASIIS#          NE     AHCCCS     uninsured      underinsured      NA      KC

 

List All Medicines you are allergic to along with the reaction you had to that medication (If more room needed, please use back of form)

List  All Medications you are currently taking ( including how much). (If  more room needed, please use back of form)

Medicine Allergy

Reaction

Medicine Allergy

Reaction

 

 

 

 

Medication

Dose

Medication

Dose