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 parent or guardian.
  • Bring a copy of the child’s shot record.
  • Have child’s social security number.
  • Bring insurance card if insured.
  • Speed up the process by printing and filling out this form beforehand.

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
The Lutheran Foundation
Physicians Health Plan
The St. Joseph Community Health Foundation