Form ADPH Imm 66 is a form that you may need to file with the Alabama Department of Public Health in order to change your name or gender marker on your driver's license, ID card, or birth certificate. The form can be downloaded from the ADPH website, and must be filled out and submitted with copies of all required documents. If you have any questions about how to fill out the form or what documents you need to provide, please contact the ADPH by phone or email.
| Question | Answer |
|---|---|
| Form Name | Form Adph Imm 66 |
| Form Length | 1 pages |
| Fillable? | No |
| Fillable fields | 0 |
| Avg. time to fill out | 15 sec |
| Other names | Bracket, RT, Medicaid, Influenza |
Alabama Department of Public Health
Vaccine Administration Form
THIS FORM MUST BE FILLED IN COMPLETELY BEFORE WE CAN GIVE YOU A FLU SHOT
PLEASE PRINT
Last Name |
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First Name |
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MI |
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Group # |
Contract # |
Date of Birth |
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Age |
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Street Address |
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City |
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I give permission for my child or myself to receive the vaccine indicated. I authorize payment for the vaccine provided. I have received notice of my privacy rights and I have been given or offered a copy of the Alabama Department of Public Health “Notice of Privacy Practices.”
Signature: __________________________________________________________________________________________________
OFFICE USE ONLY
Date of Vaccine and VIS Given |
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Type and Date of VIS |
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Clinic Site |
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Vaccine Given |
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Manufacturer and Lot Number |
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Site of Injection |
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Route |
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Influenza |
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LT |
RT |
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SQ |
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Signature of Nurse |
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Income Assessment: Medicaid Y____ N____ American Indian/Alaskan Native Y____ N____ Insurance Y____ N____ |
Family Size________ |
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Annual Income $________________ |
Payment Bracket_____ Fee Paid_____ Fee Waived_____ |
Initials of Assessor________ |
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