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SHAWNEE COUNTY HEALTH DEPARTMENT - Registration Form

Please complete at least 2 business days before coming to the Shawnee County Health Department (SCHD).

This form is intended for use by individuals coming to the SCHD Walk-In Immunization Clinic located at 2115 SW 10th Ave, Topeka, KS. If you have any questions, please call 785-251-5700.

By completing this now, you will save 15-20 minutes in the waiting room on the day of your visit. If you close your browser window before completing, you will need to start at the beginning.

Remember to bring your photo ID and insurance card with you when you come.

1. Client's Full Name:

First Name *This question is required.

Middle Initial

Last Name *This question is required.

2. Client's Preferred Name:

3. Client's Date of Birth: (MM/DD/YYYY) *This question is required. This question requires a valid date format of MM/DD/YYYY.

calendar

4. Client's Gender: *This question is required.

5. Does the Client have a Primary Care Physician:

Primary Care Physician's Name:

6. Client's Race (select all that apply): *This question is required.

American Indian or Alaska Native
Asian
Black or African American
Native Hawaiian or other Pacific Islander
White
Unknown
Other Please enter an 'other' value for this selection.

7. Client's Ethnicity: *This question is required.

Please enter an 'other' value for this selection.

Client's Origin:

Please enter an 'other' value for this selection.

8. Is the Client a Minor: *This question is required.

Client's Address:

Street *This question is required.

Apt #

City *This question is required.

County *This question is required.

State *This question is required.

Zip *This question is required. This question requires a valid number format.

Client's Phone Number (do not include dashes): *This question is required. This question requires a valid number format.

Client's Email:

Client's Preferred Language:

Can the client be contacted at the above address?

Can the client be contacted at the above telephone number?