UT Health Services Forms
For your convenience, download and print these forms prior to your visit. Please complete the forms and bring them to your appointment.
Note: UTHS forms and Vaccine Information Statements are in PDF format and can be downloaded and printed. If you do not have Adobe Acrobat Reader, you can download and install a copy from Adobe's Web site.
|Medical Records Request Form||Registration Form|
|Patient History Form||Worker's First Report of Injury|
|Pre-Travel Health Consultation|
Vaccine Information Statements
Vaccine Information Statements (VIS) are information sheets produced by the Centers for Disease Control and Prevention (CDC) that explain to vaccine recipients, their parents or their legal representatives the benefits and risks of a vaccine. Please bring your shot records with you.
|Anthrax - Administer Only||Measles/Mumps/Rubella (MMR) - $84|
|Pneumococcal Polysaccharide - $35||Oral Typhoid - $60|
|Hepatitis A (Series of 2) - $78 each||Meningococcal - $130|
|Hepatitis B (Series of 3) - $70 each||Influenza - $30|
|Yellow Fever - $105||Polio - $47|
|Rabies Vaccine (Series of 3) - $235 each||Varicella (Chickenpox) (Series of 2) - $215 each|
Japanese Encephalitis (Series of 2) - $361 each
Vaccine Information Sheet
|Typhim Vi - $60|
|Tetanus/Diphtheria/A-cellular Pertussis (TDAP) - $50||Tetanus Only- $35|
|Human Papillomavirus (HPV) (Series of 3) - $245 each||Shingles - $255|
|* Please note that there is an additional fee of $11 per vaccine for administration.|