New Submission

Insurance Information

Does your teen have insurance?*field type radio button
Does your teen have insurance?YesNo
Insurance
×
- Insurance Company Name*field type single line
  Input blocked. Maximum character limit of 4000 characters reached.
- Member ID#*field type single line
  Please include all letters and numbers
  Input blocked. Maximum character limit of 4000 characters reached.
- Group #*field type single line
  Enter 0 if you do not have a group #
  Input blocked. Maximum character limit of 4000 characters reached.
- Claim Submission Addressfield type single line
  Not Providing a claim address could result in a failure to submit your claim and you may be billed.
  Input blocked. Maximum character limit of 4000 characters reached.
- Insured Name*field type single line
  As appears exactly on insurance card
  Input blocked. Maximum character limit of 4000 characters reached.
- Insured Social Security #field type number
  Numbers Only
- Relationship to Patient*field type drop-down
- Insured Date of Birth*field type date
- Front of Insurance Card*field type file upload
  Drop files here
  You have reached the maximum file limit: .
- Back of Insurance Card*field type file upload
  Drop files here
  You have reached the maximum file limit: .
- Is insured address different?*field type radio button
  Is insured address different?YesNo
- Street Addressfield type single line
  Input blocked. Maximum character limit of 4000 characters reached.
- Cityfield type single line
  Input blocked. Maximum character limit of 4000 characters reached.
- Statefield type single line
  Input blocked. Maximum character limit of 4000 characters reached.
- Postal / Zip Codefield type single line
  Input blocked. Maximum character limit of 4000 characters reached.
Add Secondary Insurance

Vaccine Requested

Please check mark which vaccines(s) you would like your teen to receive*field type checkbox
Please check mark which vaccines(s) you would like your teen to receiveTdap (Required for 7th grade)Meningococcal ACWY (Required for 7th & 12th grade)Human Papillomavirus (Recommended)Meningococcal B (Recommended 16-18Yrs)

Health Screening

Is your teen sick today?field type radio button
Is your teen sick today?YesNo
Does your teen have allergies to medications, food, a vaccine component or latex?*field type radio button
Does your teen have allergies to medications, food, a vaccine component or latex?YesNo
Please Describe*field type single line
Input blocked. Maximum character limit of 4000 characters reached.
Has your teen had a serious reaction to a vaccine in the past?*field type radio button
Has your teen had a serious reaction to a vaccine in the past?YesNo
Please Describe*field type single line
Input blocked. Maximum character limit of 4000 characters reached.
Has your teen had a brain or other nervous system problem?*field type radio button
Has your teen had a brain or other nervous system problem?YesNo
Please Describe*field type single line
Input blocked. Maximum character limit of 4000 characters reached.
Has your teen ever felt dizzy or faint before, during or after a shot?*field type radio button
Has your teen ever felt dizzy or faint before, during or after a shot?YesNo
Please Describe*field type single line
Input blocked. Maximum character limit of 4000 characters reached.
Has the patient ever received a dose of COVID-19 vaccine?*field type radio button
Has the patient ever received a dose of COVID-19 vaccine?YesNo
Please Describe*field type single line
Input blocked. Maximum character limit of 4000 characters reached.
Has the patient ever been diagnosed with a heart condition (myocarditis or pericarditis) or have they had Multisystem Inflammatory Syndrome (MIS-C) after an infection with the virus that causes COVID-19?*field type radio button
Has the patient ever been diagnosed with a heart condition (myocarditis or pericarditis) or have they had Multisystem Inflammatory Syndrome (MIS-C) after an infection with the virus that causes COVID-19?YesNo
Please Describe*field type single line
Input blocked. Maximum character limit of 4000 characters reached.
Is your teen pregnant?*field type radio button
Is your teen pregnant?YesNo
The Delaware Public Health District may keep this record in the patient’s medical file. DPHD will record what vaccine or service was given, the date the vaccine or service was given, the name of the company that made the vaccine, the vaccine lot number, the signature and title of the person who gave the vaccine, and the address where the vaccine was given and any screening or service provided with date and person providing the service. I understand that this information will be released to a state-wide Immunization Registry for the purpose of immunization tracking recall and recording, unless I request otherwise. I understand that this information will be released and received from a healthcare provider interoperability Hub (e.g. carequality/ commonwell) for the purpose of sharing and providing patient care, unless I request otherwise. I understand that appointment, cancellation, and reminder information will come to me through email, phone call, and/or text, unless I request otherwise. I understand these permissions will be valid until revoked. For TB: The clinic will keep this form for seven years if result is negative and permanently if the result is positive. It will include information when TB test was given, PPD lot #, result and name and address of where the test was given.

I have read or have had explained to me the information sheet about the vaccine, TB test, or service to be received today. I have had a chance to ask questions, and they were answered to my satisfaction. I believe I understand the benefits and risks of the vaccine or service and ask that the vaccine or service be given to the person named above for whom I am authorized to make this request. Except as outlined above and in the notice of privacy practices, my medical information will not be shared without an authorization to release information. I have received the Health District’s Notice of Privacy Practices (HIPAA) and it is also located on our website at delawarehealth.org. I authorize my insurance company to assign the amount payable directly to DPHD. I understand that I am financially responsible for all the charges that are not covered under my insurance plan or elective service. I acknowledge that any co-payment is due and payable on the date services are received.

To view the HIPAA statement Click Here
To view the Vaccine Information Statement Click Here
To view the COVID EUA Fact Sheet for individuals 6 months through 11 years of age Click Here

Scheduling Information

Please choose your location*field type drop-down
Please choose a time*field type drop-down
I acknowledge that if my teen receives any of the above selected vaccines before the scheduled clinic I will call 740-203-2040 to inform DPHD*field type checkbox
I acknowledge that if my teen receives any of the above selected vaccines before the scheduled clinic I will call 740-203-2040 to inform DPHDI acknowledge

Signature

Parent/Guardian Name*field type single line
Input blocked. Maximum character limit of 4000 characters reached.
Relationship to Patient*field type drop-down
Parent/Guardian Signature*field type signature

Yearfield type single line
Input blocked. Maximum character limit of 4000 characters reached.
This field contains a calculation error.
References: Clinic Scheduled Date

School Teen Consent Form

Teen Demographics

Insurance Information

Insurance

Vaccine Requested

Health Screening

Scheduling Information

Signature