• Flu Vaccine Clinic Registration Form

    JCHD Drive Through

  • Jefferson County Health Department will be providing the Flu vaccine on site at our Hillsboro location on 10/2/26. This Drive-through event is open to the public. This form will close on 9/30/26 at 11:45pm. Registrations after the form closes will not be accepted.

    Please note that if you have Tricare or Mercy insurance, there is a chance you will receive a bill. 

    If you would like to to be vaccinated, please complete the form by the closing date and time. Thank you.

  • Patient Information

  • Patient Date of Birth*
     - -
    2 digit month, 2 digit day, 4 digit year
  • Format: (000) 000-0000.
  • Would you like to sign up for our Patient Portal to access your patient records? (If yes, please provide an active email address above to receive sign up information)*
  • Patient Race*

  • Patient Insurance Information

    Tricare or Mercy Insurance may result in a bill
  • What insurance coverage does the patient have?*
  • Private Insurance Information*
  • Browse Files
    Drag and drop files here
    Choose a file
    Cancelof

  • Vaccine Request

    *Conditional depending on vaccine eligibility according to vaccine record
  • Will the patient be 65 years old or older at the time of the event?*
  • You are eligible for the High Dose Flu Vaccine. Would you like to receive the High Dose option?*
  • Would you like to receive a Covid Vaccine as well during this event?*
  • Browse Files
    Drag and drop files here
    Choose a file
    Cancelof

  • REMINDER

    You may receive an appointment reminder stating that the patient has an appointment at our office. However, for this event, there is no specific appointment time. Plan to arrive at our office at your convenience during the event hours. 

     

  • Screening Checklist for Contraindications to Vaccination

  • Please answer the following questions truthfully to help determine eligibility for receiving the influenza vaccine. A "Yes" response will not necessarily deem you ineligibile. If further questions are required, our office will reach out to you prior to the event.

  • Does the patient have any severe allergies to a medication, food, vaccine component or latex?*
  • Has the patient had an allergic reaction after a previous dose of the influenza vaccine?*
  • Has the patient had a serious reaction to any vaccine in the past? (difficulty breathing, needing epinephrine, medical care required after injection, etc.)*
  • Does the patient have any health issues such as heart disease, lung disease, asthma, kidney disease, metabolic disease (diabetes), anemia, or other blood disorder?*
  • Does the patient have seizures or other nervous system problems?*
  • Does the patient have cancer, leukemia, HIV/AIDS, or any other immune system problem?*
  • In the past 3 months, has the patient taken medications that affect the immune system such as prednisone, other steroids, or anticancer drugs, drugs for the treatment of rheumatoid arthritis, Chron's disease, or psoriasis or had radiation treatments?*
  • In the past year, has the patient received a transfusion of blood or blood products or been given immune globulin or antiviral drugs?*
  • Is the patient pregnant or is there a chance they could become pregnant during the next month?*
  • Has the patient received any vaccinations in the past 4 weeks?*
  • Has the patient ever had Guillain-Barre Syndrome? (muscle weakness and/or paralysis)*

  • Acknowledgement of Receipt of Notice of Privacy Practices for Protected Health Information (HIPAA): I, the undersigned patient, or personal representative of the patient named below, acknowledge that I have read and been offered a copy of Jefferson County Health Department’s current Notice of Privacy Practices for Protected Health Information on the date set forth below. [45 CFR164]

    Consent to Medical Care: I request and consent to the medical care and diagnostic treatment procedures as determined necessary by my physician(s) or his/her assistants. I acknowledge the care I receive while in this facility is under the direction of my physician(s I understand the benefits and risks and hereby consent to vaccines, evaluation, testing, and treatment by my Jefferson County Health Department physician and his/her designee.

    Payment for Medical and Related Care: I agree to pay the facility’s set and established charges incurred for the care I receive as ordered by my physician(s) at this facility, including separate charges by independent contractors (such as labs I guarantee full payment of all charges unless restricted by Medicare or Medicaid.

    Assignment of Benefits: I hereby assign all of my rights and benefits under my existing policies of insurance providing coverage and payment for any and all expense incurred as a result of services and treatments rendered by the facility, affiliated physicians, and/or other independent contractors, and authorize direct payment to these parties for such services and treatment. I understand that most health insurance policies, including Medicare and Medicaid, are secondary payers to any existing liability policies, no-fault insurance, workers compensation or any other sources of payment that may or will cover expenses incurred for services and treatment. 

    Communication Concerning Services and Debt Collection: I authorize this facility to communicate with me for any reason related to the provision of services, including collection of amounts owed for services, using text messaging services, an automated telephone dialing system or prerecorded voice at the telephone number(s) I provided, including a telephone number assigned by a cellular telephone service or any service for which I am charged for the call. In addition, I consent to and agree that any calls between this facility and I may be monitored or recorded for any purpose. If debt collection becomes necessary, I also authorize this facility, including any collection agency or debt collector hired by this facility to check my credit and employement history, obtain a copy of my consumer report and obtain personal information from any consumer reporting agency. In the event your account goes to an outside collection agency we will add 28% collection fee to any outstanding balance due. 

    Payment for Minors: If a minor is brought in for services by someone other than the parent, custodial parent, legal guardian, etc, the charges are to be paid at the time of service by the person bringing the child in. In the case of non-custodial parent having responsibility for medical bills, the person bringing the child in must pay at the time of service and make their own arrangements with the responsible party for reimbursement. I assume responsibility for payment of charges not covered by my insurance, unless I am a minor seeking confidential services. 

    Acknowledgement and Certification: By signing this form, I certify that I am the patient or the patient's legal representative, I have read this Conditions and Treatment Form, I was given the opportunity to ask questions and I understand and accept all terms herein.

  • Date/Time
  • Should be Empty: