Transcript Jan 2009 Please Print NG# Immunization Registration Form Last Name First Name Previous/Maiden Name Sex Male Number Middle Initial Legal Guardian / Parent Name Date of Birth Female Month Date Street Name City Year Apt Number County State Home Phone Number ZIP Code Cell.

Jan 2009
Please Print
NG#
Immunization Registration Form
Last Name
First Name
Previous/Maiden Name
Sex
Male
Number
Middle Initial
Legal Guardian / Parent Name
Date of Birth
Female
Month
Date
Street Name
City
Year
Apt Number
County
State
Home Phone Number
ZIP Code
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
oAsian
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)
o Client Refuses to sign receipt of Privacy Notice.
Staff Signature and Date
Date