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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 one week 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


Other Medical Forms