Patient Intake

Patient Intake

Patient Intake Forms

To help your vaccination appointment run smoothly, all required forms must be completed before your scheduled clinic visit.

Please provide accurate and complete information, including your contact details, health history, vaccine information, and insurance details when applicable. Having this information in advance allows our clinical team to review your eligibility, prepare for your visit, and reduce delays on clinic day.

Before You Begin

Please have the following available:

  • A valid photo ID
  • Your insurance card, if applicable
  • Your current vaccination record, if available
  • A list of medications, allergies, and relevant health conditions

Complete one form for each person receiving a vaccination.

Patient Intake Form
Patient Intake Form (Spanish)

Your information will be submitted securely and used only to support your vaccination services. Completing this form does not guarantee vaccine eligibility. Final eligibility will be confirmed by the clinical team at the time of service.

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Patient Intake Forms