Vaccine Permit (Please fill out completely) - muskingum 2025

1. Click ‘Get Form’ to open it in the editor.
2. Begin by entering the date at the top of the form. This is essential for record-keeping.
3. Fill in your primary care doctor's name and Medicare number, if applicable.
4. Complete your personal information: first name, middle initial, last name, street address (no P.O. Box), city, state, zip code, county, age, and phone number.
5. Indicate whether you have Medicaid and insurance by selecting 'Yes' or 'No'.
6. Provide your email address for communication purposes.
7. Carefully read and sign the agreement regarding vaccine risks and benefits. If signing on behalf of someone else, indicate your relationship.
8. Answer all health-related questions truthfully to ensure safety during vaccination.
9. For clinic use only: Leave this section blank; it will be filled out by healthcare personnel after your visit.

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