Guilford County Department of Health and Human Services

Public Health Division

Immunization Permission Form

Immunization Permission Form

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Date Submitted

Child Name

First Name

Middle initial

Last Name

Child Date of Birth

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Age

Childs Full Birth Date

Child Information

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SSN

Address

City

Zip Code

Parent Daytime Phone Number

Parent Evening Phone Number

Parent Email

Emergency Contact

Contact Name

Contact Phone Number

Contact's Relationship to Child

Agreement Section

To receive Tdap and/or Meningococcal and/or MMR vaccine(s) at his/her school. I have received, read, and understood the Vaccine Information Sheet(s) about the disease(s) and for the vaccine(s) listed.
I have had an opportunity to have my questions answered by my child’s medical provider or by the Guilford County DHHS – Public Health Division to my satisfaction.

I have received, read, and understood the information in the attached Health Insurance Portability and Accountability Act HIPPA consent.

I give authorization to Guilford County DHHS – Public Health Division to disclose specific health information for my child for the purpose of treatment, payment, and/or operations as stated in the HIPAA consent

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Immunization Questions

Please select “Yes” or “No” for each of the following questions. All questions MUST be answered for your child to receive Tdap and/or Meningococcal and/or MMR vaccine(s) at his/her school.

Does your child have any allergies, including to either vaccine or any agents used to make the vaccine(s)? Value is not selected

Has your child received other vaccines in the past month? Value is not selected

Has your child received any antibody or blood products in the past 11 months? Value is not selected

Does your child have a history of Guillain-Barré Syndrome? Value is not selected

Has your child had a seizure after receiving DTP/DTaP? Value is not selected

Does your child have seizures, nervous system disorders, or immunosuppression from disease or therapies (e.g. cancer, taking high dose prednisone daily)? Value is not selected

Is your child pregnant? Value is not selected

Date of last Menstrual Period

Who is your child’s medical doctor (or practice name)?

Insurance Information

Please note for Payment (as noted in the HIPAA Notice of Privacy Practices):
We may use and disclose your medical information so that the treatment and services you receive at the health department may be billed and payment may be collected from you, insurance companies, or third-party payers. I, the parent/guardian understand that I am responsible for all charges not paid by my insurance plan except those amounts that the Clinic is contractually obligated to write off.

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Medicaid Number

United Health Care policy number

United Health Care group number

United Health Care name of PCP listed on card

Blue Cross Blue Shield policy number

Blue Cross Blue Shield group number

Blue Cross Blue Shield name of PCP listed on card

Name of insurance provider

Policy number

Group Number

Name of PCP listed on card

Insurance will be filled for children with insurance (including Medicaid, UHC, BCBS).
There is no cost for uninsured children.
Please call 336-641-6889 if your child is covered by an out-of-network insurance

Parent/Guardian signature

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Public Health - Immunization Permission Form