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Forms
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.

Medical Records Request Form
       - PDF version
Registration Form
       - PDF version

Patient History Form
       - PDF version

Worker's First Report of Injury
      - PDF version

Vaccine Information Statements (VIS)

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.

Note: Most UTHS forms and Vaccine Information Statements are in pdf format. They may be downloaded, and printed. If you do not have Adobe Acrobat Reader, you can download and install a copy from Adobe's Web site.

Anthrax - Administer Only
       - PDF version
Measles/Mumps/Rubella (MMR) - $62
       - PDF version
Pneumococcal Polysaccharide - $30 
       - PDF version
Oral Typhoid - $55
       - PDF version
Hepatitis A - (Series of 2) $70 each
    
   - PDF version
Meningococcal - $125
       - PDF version
Hepatitis B - (Series of 3) $60 each
       - PDF version
       - Text version
Influenza - $25
       - PDF version
       - Text version
Yellow Fever - $98
       - PDF version
Polio - $42
       - PDF version
Rabies Vaccine - (Series of 3)
$230 each
       
- PDF version
Varicella (Chickenpox) - (Series of 2)
$100 each
       - PDF version
JE-VAX - (Series of 3) $147 each
       - PDF version
Typhim Vi - $55
       - PDF version
Tetanus/Diphtheria/A-cellular Pertussis (TDAP) - $45
       - PDF version
       - Text version
Tetanus Only- $30
       - PDF version

Human Papillomavirus (HPV) -
(Series of 3) $240 each
       - PDF version

Shingles - $250
       - PDF version
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Phone: (713) 500-3267  Fax: (713) 500-3263
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