In-Home Vaccinations Home Visiting Step 1 of 6 - Event 16% Please complete each section and submit the form.Referring Agency(Required)Select AgencyHealthier Moms and BabiesBenchmark- HomePointeJourney Beside MothersPlease tell us how you heard about our home visiting program. Child’s Information:Child Name(Required) First Middle Inital Last Child's Date of birth(Required)Month123456789101112Day12345678910111213141516171819202122232425262728293031Year2025202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Sex(Required)Select OneMaleFemaleHome Address(Required) City(Required) State(Required)AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingZip(Required) Race(Required)Please Select OneWhiteAfrican AmericanAsianAmerican IndianNatl. Hawaiian, Pac IslAlaskan NativeOtherEthnicity(Required)Please Select OneHispanic/LatinoNot Hispanic/LatinoDeclined to answerLanguage(Required)Please Select OneEnglishSpanishBurmeseOtherChild's Primary Care Provider(Required) Is the Child Disabled?(Required) Yes No Prefer not to say Does the student have any of the following:(Required) ADHD Autism or ASD Anxiety or Depression ODD Hearing loss/Deafness Vision loss Physical impairment in one or more limb Learning or intellectual impairment Neurological disorder (Epilepsy, MS, Muscular Dystrophy) Speech or language difficulties None of these apply Super Shot understand that some students may need extra accommodations to make sure that the vaccination process goes as smoothly as possible. If extra accommodations are needed, call (260) 424-7468 to make an appointment at our office located at 1515 Hobson Rd, Fort Wayne, IN 46805. Our Sensory room is available during clinic hours for patients of any age. Contact Information:Parent/Guardian Name(Required)First NameMiddle InitialLast Name Add RemoveMobile Phone Number(Required)Email Address(Required) Number of People in HouseholdPlease Select One12345678910+Choose not to answerCurrent Household Income(Required)Please Select OneBelow $11,800$11,881-$24,300$24,301-$36,450$36,451-$48,600$48,601-$60,750$60,751-$72,900Over $72,901Decline to Answer Required Health Insurance Information:Select One (child's insurance status)(Required) Private Insurance Medicaid (ex: Healthy Indiana Plan, Hoosier Care Connect, Hoosier Healthwise) No Insurance: I certify that the patient is not covered by any health insurance. Medicaid Insurance Provider(Required)Select Medicaid InsuranceAnthem BCBSCareSource-INManaged Health Services-MHSMDWiseOtherPrivate Insurance Company(Required)Private Insurance CompanyAetnaAnthem BCBSCareSourceManaged Health Services-MHS AmbetterCignaMDWiseParkview Signature Care - Signature CarePHP of Northern IndianaUnited HealthcareThree Rivers PreferredLutheran PreferredOther (Enter Below)Other Insurance Company(Required) Member ID(Required) Group #(Required) Policy HolderName(Required) First Middle Initial Last Date of Birth(Required)Month123456789101112Day12345678910111213141516171819202122232425262728293031Year2025202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Employer(Required) Relationship to Child(Required)Select OneSelfSpouseChildOtherGrandparentGrandchildNephew or NieceFoster ChildWardStepson or StepdaughterEmployeeHandicapped DependentSponsored DependentDependent of a Minor DependentSignificant OtherMotherFatherEmancipated MinorLife PartnerUpload Insurance Card Image (Front)(Required)Accepted file types: jpg, jpeg, heic, gif, png, Max. file size: 10 MB.Upload Insurance Card Image (Back)(Required)Accepted file types: jpg, jpeg, heic, gif, png, Max. file size: 10 MB. Medical Information:Please select Yes or No for all questions. Answers are for the person getting the vaccine.Is the child allergic to a vaccine component or latex (ex. gentamicin, alginine, gelatin, or MSG)? (if yes, please note)(Required) Yes No List vaccine component allergies(Required) Add RemoveHas the child had a serious reaction to a vaccine in the past?(Required) Yes No Describe the serious reaction:(Required) Is the child pregnant or is there a chance they could become pregnant within a month of being vaccinated?(Required) Yes No Not Applicable Is someone in the child's home immunocompromised or requires a protective environment?(Required) Yes No Does the child have any of the following: (mark all that apply)(Required) Chronic Heart Disease Diagnosed with Myocarditis or MIS-C Kidney Disease Liver Disease Crohn's Disease Psoriasis Complement Component Deficiency Asplenia Takes a medication that lowers resistance to infection Takes aspirin or Blood thinners History of Chickenpox History of Gillian-Barre syndrome Diabetes/Metabolic Disorder History or family history of Nervous System Disorder Asthma/RAD Received blood products or immune gamma globulin in the last year CSF Leak Cochlear Implant Weakened Immune System, Cancer, Lupus, HIV/AIDS None of the above A Super Shot staff member will review your child's vaccine records via CHIRP, Indiana's Vaccination Registry, to indentify which vaccines your child needs. Once all information is collected and prepared, the staff member will reach out to the number you listed on this registration form to schedule a home visit with you. If you do not hear from us within 5 business days, please call the office at (260) 424-7468. Communication It's ok to call me It's ok to TXT me The HIPAA Notice of Privacy Policy available at https://supershot.org/privacy-policy/ CDC Vaccine Information Statements for any vaccines the child named above may receive are available at https://www.cdc.gov/vaccines/hcp/vis/current-vis.html I have read and understand all information provided at the links above and understand the benefits of vaccines, as well as the risks which includes the contraindications, precautions, and possible side effects of each vaccine administered. I give Super Shot permission to communicate information provided with other healthcare providers as needed, for EMR data entry, insurance billing for services provided, and storage according to Indiana Department of Health policies. I relieve Super Shot, Inc and all personnel of any liability for any reactions that may occur. I have the legal authority, based on my relationship to the child named above, to consent to vaccine administration.Parent/Guardian Signature(Required)Date(Required) MM slash DD slash YYYY Parent/Guardian Name(Required)
