• CSKT Tribal Health COVID Vaccine Request Form

    * Please fill out the required details below
  • Vaccine supply is limited. Filling out this form will not guarantee an appointment in the order in which it was received. Vaccines are prioritized to those who are most vulnerable. Moderna vaccine is for 18 years and older, Pfizer vaccine is for 16 years and older. Please call Tribal Health at (406) 745-3525 with questions. 

  • Personal Information

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  • Signatures

    Please read this statement and the Emergency Use Authorization (EUA). By signing below, you are agreeing that you have had a chance to ask questions and were provided satisfactory answers and you believe the benefits outweigh the risks of the COVID-19 vaccine to be given today. Signing this form verifies the patient or guardian has read the COVID-19 Vaccine Fact Sheet and authorizes the patient named on this form to receive the COVID-19 vaccine.

  • Clear
  • I authorize Tribal Health to collect and enter immunization records for the listed patient into the Department of Public Health and Human Services Immunization Information records (ImMTrax). ImMTrax is a confidential computer system that contains immunization records. I understand that information in the registry may be released to a public agency, the patient’s healthcare provider(s), and other facilities such as schools. I understand that I can revoke my authorization and have my record removed at any time by contacting my local Health Department. By signing below, I agree to allow immunization information to be entered into ImMTrax.

  • Clear
  • By clicking the "Submit" button below, you certify that the above information is correct and accurate to the best of your knowledge. All information is confidential and is accessed only via a secure, encrypted interface.

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