We've detected that Javascript is not enabled. It is required for an optimal survey taking experience.
Please check your browser's settings and make sure Javascript is turned on. Learn how to enable Javascript.

Skip survey header

Immunizations Clinic Appointment Request- Midland County Department of Public Health

Use this form to request an appointment with the Immunizations Clinic at the Midland County Department of Public Health (MCDPH).

Vaccine(s)
Tuberculosis (TB) Test
Vaccine Questions
Non-Medical Vaccine Waiver

Appointment requests will be reviewed during normal clinic hours (Monday-Friday 8am-5pm), and we will contact you to schedule an appointment based on your responses.

If you are experiencing a medical emergency, call 911 or proceed to the nearest emergency room.

This form is secure and HIPAA-compliant. Please provide as much detail as possible.

1. Are you scheduling an appointment on behalf of a minor? *This question is required.

If scheduling an appointment for a minor, please provide some additional information:

Your Name:
Relationship to person you are scheduling services for:

2. First and Last Name (legal name) of the person who will be receiving services: *This question is required.

First Name
Last Name

3. Preferred name of the person receiving services:

4. Date of birth for the person receiving services? MM/DD/YYYY *This question is required. This question requires a valid date format of MM/DD/YYYY.

calendar

5. Birth sex for the individual receiving services: *This question is required.

6. Tell us how we can help you (select all that apply): *This question is required.

I would like to make an appointment for a vaccination or multiple vaccinations
I would like to make an appointment for a Tuberculosis (TB) Test
I would like to make an appointment with an Immunizations Clinic nurse to ask questions
I would like to make an appointment for a non-medical waiver
Other - Write In Please enter an 'other' value for this selection.

7. What day of the week works best for you (select all that apply):
Note- All services may not be available on all days of the week. *This question is required.

8. What time of day works best for you (select all that apply): *This question is required.

We accept the insurance listed below, please check all that apply.

If your insurance is not listed, we may be able to help connect you with an alternate provider.
If you do not have insurance, we offer many services on a sliding fee scale based on income.
- An uninsured child will not be denied access to vaccines due to inability to pay.
- Vaccine administration fee may be waived for any child or adult receiving free vaccine (Vaccines for Children, Adult Vaccine Program (AVP), Special Funds) in any case of inability to pay.

*This question is required.

10. When we contact you to schedule an appointment, how may we contact you? *This question is required.

Phone call
Text- Please note, this is not a confidential method of communication, so no personal information will be sent aside from an appointment day/time.
E-mail- Please note, this is not a confidential method of communication, so no personal information will be sent aside from an appointment day/time.
Current client registered in Patient Portal

11. What is your phone number? *This question is required.

12. What is your e-mail address? *This question is required.

13. What is your address?

Street Address
City
State
Zip Code

14. Is there anything else you would like us to know?