evvax.com

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