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Patient Forms

Beginning in June 2016 our immunization clinic will be by appointment only. New patients will need to pre-register by submitting their intake forms, immunization records (for patients 18 and under), and a front-and-back copy of their insurance card(s) at least 3 days prior to the appointment. Please choose one of the following ways to submit your information:

Fax: 304-728-3319 – Attention Immunizations
Email: JeffersonLHD@wv.gov – patient name as subject 
In Person: At the address below between 8:30am & 4:30pm, Monday-Friday
Mail:Jefferson County Health Department – Clinical Office
1948 Wiltshire Road, Suite 1
Kearneysville, WV, 25430

Immunization Forms

Immunization Patient Form
Vaccines For Children Program Form (patients 18 and under)

Other Medical Forms

Authorization to Release or Obtain Records
Family Planning Program Basic Data Form
TB Risk Assessment Form
TB Risk Assessment Form (Spanish)