Monroe County, NY - Vaccine Registration Form

SCHOOL VACCINATION REGISTRATION FORM

This form is for back-to-school required TDAP and Meningitis vaccine appointments. Age 10-19 only. For any other vaccinations please contact the immunization department.

* Required Fields

Your Email Address *

Confirmation of appointment will be sent to this email.

Pick a Vaccine Site

# People You Are Scheduling: Max: 4

Pick a Date *

Available date/time Unavailable Selected

Pick a Vaccine, Location, & Time *

Recipient

Show/Hide Delete This Person

Which vaccines are needed? *
TDAP (6th Grade) Meningitis MCV4 (7th & 12th grade)
If other vaccines are needed please contact the Immunization Department

First Name *

Last Name *

Middle Name

Date of Birth *

Phone * Copy From Person #1

Email * Copy From Top Email

Address * Copy From Person #1

Address (Line 2, Apt, Etc.)

City *

State *

Zip *

Special Accommodations Needed (wheelchair access, translator, etc.)

Mother's First Name (if age < 19)

Mother's (Maiden) Last Name

Insurance Information

Bring your insurance card with you to appointment! If you do not wish to provide your insurance information, select "No Insurance"

Insurance Type/Provider *

If "Other", Specify

Insurance ID # *

Relationship to Recipient *

Enter name of primary subscriber if relationship is not "self" of if name on card differs from recipient name entered above.

Primary Subscriber Last Name

First Name

Middle Name

Primary Subscriber Date of Birth

Primary Subscriber Gender

Enter address of primary subscriber if different than the recipient address entered above.

Primary Subscriber Address

Primary Subscriber City

State

Zip

Guardian/Emergency Contact (optional)

First Name

Last Name

Middle Name

Phone #

Relationship to Recipient

Add Another Person

YOU WILL NOT BE ABLE TO EDIT THIS INFORMATION AFTER CLICKING THE SUBMIT BUTTON BELOW. PLEASE MAKE SURE ALL INFORMATION IS CORRECT.