The heart of community health

Patient Forms

Before coming to a Super Shot clinic, every child or adult who intends to receive a vaccination needs to be prepared with the following:

Children (under 18 years of age) must bring:

  • We serve Medicaid, uninsured, and underinsured children from birth to age 18.
  • Must be accompanied by a parent or guardian.
  • Bring a copy of the child’s shot record.
  • Have a child’s social security number.
  • Bring insurance cards if insured.
  • Speed up the process by printing and filling out this form beforehand.
  • Additionally, non-parent guardians must bring this form.

Adults (over 18 years of age) must bring:

  • We serve uninsured and underinsured adults.
  • Bring a copy of your shot record.
  • Have your social security number.
  • Speed up the process by printing and filling out this form beforehand.

 

Shot records can be found by contacting your primary care doctor or by going to MyVaxIndiana.

 

 

Thanks to our community partners

Community Foundation of Greater Fort Wayne
PHP Foundation
The James Foundation
The St. Joseph Community Health Foundation
English Bonter Mitchell Foundation