Medical & Dental Forms; Job Application; Surveys; COVID-19 Press Release; MRC Application

Forms and Applications and Policies

COVID CLINIC Forms –

Do not fax, email, or mail forms to DCHD

Please complete the forms below prior to your upcoming appointment at one of our vaccine clinics.

Completing them in advance of your appointment will expedite your check-in process at the clinic.

Thank you.

DCHD_ENGCOVID-19 Moderna Consent

ENG-pre-vaccination-screening-form

ENG-Fact-sheet-recipients-caregivers-Moderna COVID-19 vaccine

SPANISHCOVID-19 Moderna Consent

SPANISHeua-fact-sheet-recipient

√ Current Community Surveys for Douglas County, Illinois

DCHD Job Application

DCHD_MRC_APPLICATION

Immunization Forms

New Flu Consent Form

Child Flu Consent Form 2018

Info Release

Communication Consent

Questionnaire

VFC – Vaccinations for Children Program

Dental Registration Forms

Dental Exam Form

Temporary Food Permit

HIPAA Consent Forms

HIPAA Policy

Septic

Plan Reviews