Get Adph Imm

Navigating the Adph Imm form is an important step in ensuring accurate vaccination records and proper administration of vaccines. This guide provides you with clear, step-by-step instructions to successfully fill out the form online.

Follow the steps to efficiently fill out the Adph Imm form.

1. Click ‘Get Form’ button to obtain the form and open it in the editor.
2. Begin by entering your last name in the designated field. Ensure you print your name clearly.
3. Next, input your first name followed by your middle initial, if applicable.
4. Select your gender from the provided options.
5. Indicate your race by selecting the appropriate option from the choices available.
6. Enter your insurance policy number, or provide your Medicaid or Medicare number as needed.
7. Fill in your date of birth in the required format.
8. Specify your age in the designated field.
9. If applicable, enter your group number.
10. Provide your street address, ensuring all details are correct for accurate delivery of services.
11. Enter your phone number so that the clinic can contact you if necessary.
12. Fill in your city, county, and state of residence.
13. Complete the zip code field as required.
14. Affirm your consent to receive the vaccine by checking the designated box.
15. Sign and date the form to authorize payment for the vaccine and indicate understanding of privacy rights.
16. Select which vaccine is being administered from the list provided.
17. If necessary, indicate pregnancy status and receipt of additional vaccine information.
18. Fill in the date vaccines and the Vaccine Information Statement were given.
19. Record the type and date of the Vaccine Information Statement.
20. Document the clinic site, vaccine given, manufacturer, and lot number.
21. Choose the site of injection using the provided options.
22. Indicate the route of administration according to the type of injection.
23. Ensure the nurse's signature is included and complete the income assessment if needed.
24. Once all sections are filled, save the changes made to the form, and download, print, or share as necessary.

Complete your Adph Imm form online by following these simple steps.