I have been offered a copy of the Vaccine Information Statements (VIS) checked below. I have read, have had explained to me, and understand the information in these forms. I ask that the vaccine(s) checked below be given to me or the person named below for whom I am authorized to make this request. I consent to the inclusion of the immunization data in the Kansas Immunization Registry for me or on behalf of the person named below. I also consent that the vaccine(s) checked below be given to my child at school. I understand that these immunizations will be billed to my insurance (if applicable) and that I am responsible for my copayment (if any) as determined by insurance.

Hepatitis A (2 dose series)	Tdap (1 dose)	HPV (Gardasil 2 – 3 dose series)

Menactra (1 dose)	MenB (2 dose series)	Other

Signature of Patient (if 18 or older) or parent/guardian (if minor)	Date

(After giving consent, if you change your mind and do not want to complete the series, please call the Rooks Co. Health Dept. at

785-425-7352 )

Web IZ: ______________ Grade:

Ethnicity: Hispanic or Latino Yes No	Race: AS – Asian/Pacific Islander/Other HA – Hawaiian BL – Black/African American IN – American Indian/Alaska Native CA – Caucasian/White/Mexican/Puerto Rican JA – Japanese CH – Chinese NW – Other Non-White FI – Filipino UN – Unknown
IMMUNIZATION SCREENING QUESTIONNAIRE
Is the person to be vaccinated currently sick or experiencing a high fever?	Yes No
Has the person to be vaccinated had a serious reaction to a vaccine in the past?	Yes No
Does the person to be vaccinated have any allergies that produce a severe (anaphylactic) reaction?	Yes No
Does the person to be vaccinated have an allergy to eggs?	Yes No
Does the person to be vaccinated have any of the following: auto immune disorder, asthma, diabetes, lung, heart, kidney, neurological, neuromuscular, and/or liver disease or a known blood disorder?	Yes No
Is the person to be vaccinated currently taking cortisone, prednisone, other steroids, or anti-cancer drugs or x-ray treatments?	Yes No
Does the person to be vaccinated have asthma or has he/she had wheezing episodes within the last 12 months?	Yes No
Is the person to be vaccinated pregnant or thinking of becoming pregnant within the next 3 months?	Yes No
Name	Age	DOB	Sex: Male
(Last) (First) (Middle Initial)	Female
Mailing Address	City	State	Zip Code
Phone Number	County
Primary Care Physician:	Street Address	City, State, Zip	Phone Number

Please include insurance information for patient or attach a copy of insurance card

PATIENT INFORMATION
Medicaid /19 or 21/ Aetna, United Health or Sunflower:	ID#
BCBS: ID#	Group#
Name of Policy Holder	Relationship to Insured: Self Spouse Child Other