Vaccination Registration

AUTHORIZATION FOR LIMITED RELEASE OF MEDICAL INFORMATION

By completing this registration form for my child to receive immunizations from Compass Health Network, I authorize the release of all immunizations, or other proof of immunity (to include natural immunity through previous infection, or laboratory results) records from my child’s current or past school’s medical record or any previous immunization providers.

PRIVACY ACT STATEMENT The information provided will be used primarily to facilitate the appropriate administration of immunizations by Compass Health Network.

Name of student's school district

Teacher

Grade

Student ID # or SS #

Student's First Name

Student's Last Name

Student's Middle Name

Other Student Names/Aliases

Student's Date of Birth

mm/dd/yyyy

Student's Address

Preferred Language

Interpreter Needed

Yes

Race

Have you lived in a state other than Missouri in the past year?

Yes

Does the Parent/Guardian Reside at the Same Address as the Student?

Yes

Parent/Guardian First Name

Parent/Guardian Last Name

Parent/Guardian Relationship

Parent/Guardian Mobile Number

Parent/Guardian Email Address

Preferred Contact

Mobile

Insurance Status

If insured, please either provide a picture of the card, front and back, or upload at the end of the form

a. Privately insured

b. Medicaid insured

c. Underinsured

d. Uninsured - no upload required

Does your student's school have all of your vaccine records on file?

Yes

Unknown

File Upload

If you have additional vaccine records or are not sure what your school has on file for your student, please take a picture or upload a copy at the end of the form.

Please attach an insurance card if applicable, otherwise, please bring the card on the day of the event.

Drop your files here

Send me a copy of my responses

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