Patient Health Information Form

FORM – English

    Required Contact Information




    Patient Information Sheet

    Patient Information


    BRHD Facility: Tremonton Brigham City Logan South Logan Garden City Randolph

    Patient Sex: Male Female

    Patient Race:
    American Indian or Alaskan Native
    Asian
    Black or African American
    Native Hawaiian or other Pacific Islander
    White
    Hispanic
    Other




    I understand that Bear River Health Department may contact me by text or phone call to remind me of any scheduled appointment. Please DO NOT send me reminders by voice or text

    If Patient is under 18 provide the following:


    Insurance Information





    My current insurance status is:

    Uninsured. I/my child do/does not have health insurance.

    Insured. I/my child do/does have health insurance, and it covers all or part of the cost of immunizations.

    Signature of Client or ParentGuardian Representative

     

    HIPAA

    I acknowledge receipt of a copy of the Bear River Health Department (Health Department) Notice of Privacy Practices-For Protected Health Information (Notice) which I have or will carefully review, and acknowledge my rights for a more complete description and understanding of potential uses, disclosures of and/or requests for such Protected Health Information by the Health Department.

    I acknowledge that the Health Department reserves for itself the right to change the terms of its Notice at any time, and that if the Health Department does not change the terms of its Notice, I acknowledge the right to obtain a copy of the current revised Notice at any Health Department office.

    Signature

     

    Consent for Services

    I have been provided with information about the vaccine I am receiving today. I have had a chance to ask questions that were answered to my satisfaction. I believe I understand the benefits and risks of the vaccine.

    Signature

    Are you allergic to eggs? Yes No

    Click the SEND button only once. It will take just a moment to process your information. You will receive a confirmation email if your submission was successful.