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.

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.


You can review this form before your visit for reference on some information that will be needed upon a visit.

Authorization to Consent Form – If someone other than the parent or legal guardian is bringing the child to our Immunization Clinic, the parent or legal guardian must sign our Authorization to Consent to Medical Treatment for Minor Child by Non-Parent form and attach a copy of his/her driver’s license.

Please review our HIPAA policy for more information on how your medical information can be used and how you can gain access to it.

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