NM VFC Vaccine Administration Form Please fill in form - nmhealth 2026

1. Click ‘Get Form’ to open it in the editor.
2. Begin by filling in the required fields marked with an asterisk (*). Start with the 'Last Name' and 'First Name' of the person receiving the vaccine, followed by their 'Date of Birth'. Ensure you enter this information clearly using capital letters.
3. Next, provide the 'Mother’s Maiden Name', 'Mother’s First Name', and select the 'Sex' from the options provided. Continue by indicating the patient's ethnicity and race as applicable.
4. Complete the mailing address section, including city, state, and zip code. Don't forget to include both home and cell phone numbers for contact purposes.
5. In the insurance status section, mark the appropriate category that applies to your situation. If you have private insurance, specify your provider; if not, indicate if you are uninsured or part of a Medicaid plan.
6. For clinic use only, ensure that all vaccination details such as vaccine type, manufacturer, lot number, and administration site are accurately filled out by the vaccinator.

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