Health History Forms
If you are planning to visit our clinic, you can save some time by filling out these health history forms for you or your child.

Adult Health History
Child Health History

Authorization Form
If somoene other than the parent or legal guardian is bringing the child to our Immunization Clinic, the parent must have this form signed and notarized.

Authorization to consent to medical treatment for minor child of adult non-parent (must be notarized)

Vaccines for Children

• 2010 Child Adolescent Immunization Schedule

The Immunization Clinic administers free of charge the following vaccines to children through 18 years of age:

• DTaP - diptheria, pertussis, acellular pertussis
• Td or Tdap- tetanus, diptheria or tetanus, diptheria, pertussis
• Hib - human influenza type B
• Varicella - chicken pox
• IPV - injectable polio vaccine
• MMR - measles, mumps, rubella
• HEP B - hepatitis B
• HEP A - hepatitis A
• MCV4 - meningococcal
• PCV7 - pneumococcal conjugate
• Rota Teq^TM - rotavirus
• Influenza - flu (seasonal)
• HPV (Gardasil or Cervarix) - genital human papillomarivus

Due to an unpredictable vaccine supply, not all vaccines are available at all times for children.  Please call 260 449-7514 for more information.

Super Shot

• Super Shot Web Site
• 2010 Clinic times and locations
• Schedule in Spanish

 Vaccines for Adults

The Immunization Clinic offers the following vaccines to adults:

• Twinrix - hepatitis A, hepatitis B
  Free to those who meet the guidelines

Travel Immunizations

For travel immunizations, call Jeremy Markewicz with Maxim Health Care at 1-866-844-9257.

• Vaccinations for Foreign Travel
• CDC Foreign Travelers' Health

General Immunization Information

• National Immunization Program
• American Academy of Pediatrics

Vaccines for Teens