pt registration

East Valley Vaccination and Examination Center

For Office Staff Use Only

______ Medicare Contract given

Text Box: Confidential Patient Registration For Office Staff Use Only Date______________________ Date of Birth____________________________ Patient Name______________________________________________________________________________________________ Last Name First Middle Initial Address____________________________________________________________________________________________________ Street City State Zip Phone #s (H)___________________ (C)___________________ (W)________________ Mother’s Maiden Name or Guardian’s Name _______________________________________________ Vaccine Record Information (please initial on the line) ___________ 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 (circle the appropriate statement) I certify that I do NOT have Medicare insurance I certify that I do have Medicare insurance Are You Allergic to Any Medications? Yes No If “Yes”, please list type of medication and reaction: ______________________________________________________________________________________________________________________________________________________________________________________________________________________________ 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 ___Other (please list) ____________________________________ Travel Patients Only: Date of Travel ___________ Length of Travel _______________ Destination & Country _______________________ Yes – I would like my name added to the map

Initials

ASIIS# NE AHCCCS uninsured underinsured NA KC