Downloadable 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.

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
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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
Consent Form
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.
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