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2023 Patient Information Sheet
County I/we plan to attend a clinic in
Patient Race

If you have a photo of your insurance card or can take a photo of it, please upload it below.
If we do not have your insurance card the day of the clinic, you will be required to pay at that time or no vaccination will be administered.

Upload File

I have been given a copy and have read, or had explained to me, the information contained in the Vaccine Information Statement for the person receiving the vaccine(s). I understand the benefits and risks of the vaccine(s) and request that the vaccine(s) be given to me or the person for whom I am authorized to make this request. I agree that this information may be shared with schools, daycare centers, healthcare providers and others when medically necessary. I understand that it is my responsibility to know what my insurance plan covers and agree to pay the portion not covered by my insurance. I understand that if Southeast Utah Health Department does not have a contract with my insurance company, or my insurance company denies payment, I am responsible for all charges incurred. I am hereby notified that the Southeast Utah Health Department’s Notice of Privacy Practices is located on their web site at and I have had a chance to ask questions about how my public health information will be used.

Thanks for registering. See you there!


Click here for the Vaccine Information Statements.


Click here for our Privacy Practices.

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