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Client's First Name

Client's Last Name

Client's birth date

If client is a minor, Parent/Guardian's name

Best phone number

Address

Street address

Street address 2

City

State

Zip

Insurance

To help us better determine vaccine eligibility and potential costs, please provide the following information (optional):

Carrier/Company Name

Policy Number

Group Number

Uninsured

Leave a voicemail?

We do not release information to anyone who is not you or, if the client is a minor, his or her parent or guardian. Our voicemails generally say, “Hello [name], this is Catawba County Public Health. When you have a chance, please call us back at (828) 695-5881. Would you like us to leave you a voicemail?

Interpreter Needed