Patient Forms


To speak with a healthcare professional Call us at 281-313-7468 or email us at info@houstonvaccines.com

If you would like to save time you may click on the appropriate form for your type of appt and print and fill out the forms in advance and bring with you to your first appointment:

Please do not sign before visit as we need to witness signatures.

I. New Travel Patient Forms: Travel Patient Registration
1. Demographic/Consent Form
2.Itinerary and Medical Screening Form
3. Privacy and Confidentiality Form

II. New Adult Local Patient Form : Adult Patient Registration Form
1. Demographic/Consent Form: Adult Screening Form
2. Medical Screening Form
3. Privacy and Confidentiality Form
4. NEW State of Texas law re:Meningitis

III. Pediatric New Patient under 19 forms: Pediatric Patient Registration Form
1. Demographic/Consent Form
2. Immtrac Optional Statewide tracking consent form for minors: Immtrac consent for minors
3. For those that qualify for VFC Program:vfc-eligibility-form-2016
4. Medical Screening
5. Privacy and Confidentiality Form
Pediatric Screening Form
Information about privacy policy

IV. Discounted Vaccine Application

1. GSK Patient Assistance Program for Twinrix Tdap Hep A or Hep B
2. Merck Patient Assistance Program for MMR Varicella HPV or Pneumonia