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Screening Questionnaire for Vaccine Only Visits
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    For parents/guardians:

    The following questions will help us determine if your child is eligible to receive his or her vaccine(s) today.

    If you answer “yes” to any question, it does not necessarily mean your child should not be vaccinated.

    It just means additional questions must be asked. If a question is not clear, please ask your healthcare provider to explain it.

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    Pick a Date
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    Please note that if your child does not have an up-to-date physical, he or she will be ineligible to receive any vaccines today.

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    Clear
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