Immunization Registration Form

1. Please Print Jan 2009 NG# Immunization Registration Form Last Name First Name Middle Initial Previous/Maiden Name Legal Guardian / Parent Name Month Date Year Sex Male Date of Birth Female Street Name Number Apt Number City County State ZIP Code Home Phone Number Cell Phone Number ( May we contact you at this address and phone number about your medical care and billing? oYes oNo • Ethnicity and Race: Do you consider yourself Hispanic or Latino? o Yes o No • Which category best describes your race (please select ALL that apply): • o White o Black or African American o American Indian or Alaskan Native • Asian o Native Hawaiian or Pacific Islander o Other ____________________ • I give permission for Columbus Public Health staff, medical consultants and other health consultants and/or such other attending physicians or persons that shall have a reason for ministering to said client to render all such services as may be necessary to diagnose, treat and care for the needs of the above mentioned client. I understand I may request a clinical chaperone (third person) to be present during the exam. I also understand that any care received outside Columbus Public Health (e.g., x-rays, specialist care) will not be paid for by Columbus Public Health. I authorize the release of medical information necessary to process this claim for billing. I agree to pay my co-pay and for any charges not covered by insurance or grants. • o I have received a copy of the Privacy Notice at my first visit to Columbus Public Health. • Patient Signature (Parent/Legal Guardian, if Patient is under 18) Date • Client Refuses to sign receipt of Privacy Notice.Staff Signature and Date