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Child and Family Agency

Child and Family Agency

Strong | Safe | Supported

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Forms – CBC Enrollment Vaccination Only


Community Bridge Clinic Enrollment Form (for vaccines only)

Patient Information

Full Legal Name (of person receiving services)(Required)
MM slash DD slash YYYY
Address(Required)
Sex(Required)

Ethnicity(Required)
Race(Required)

Does the patient attend school?(Required)

Insurance Information

Do you have insurance (private/Medicaid/Husky)?(Required)
Insurance Address
Policy Holder Name(Required)
MM slash DD slash YYYY
Is there additional insurance?(Required)
Insurance address(Required)
Policy Holder Name(Required)
MM slash DD slash YYYY

Parent/Guardian Information (if patient is a minor)

Parent/Guardian Name
MM slash DD slash YYYY
Address (if different from patient)
I agree voicemail messages can be left for me on:

Acknowledgement and Signature

By signing below, I understand and acknowledge I have read and understand this consent:(Required)
RELEASE OF INFORMATION AND PAYMENT AUTHORIZATION(Required)
CONSENT AND ACKNOWLEDGEMENT OF PRIVACY PRACTICES(Required)
I certify that the health information provided is accurate to the best of my knowledge and understand that incorrect information can be dangerous to the patient’s health. I will notify the Community Bridge Clinic of any changes to medical information. By signing, I understand that this authorization is valid until I revoke this authorization. I understand I may revoke this authorization at any time by submitting written notice of the withdrawal of my consent.
MM slash DD slash YYYY
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