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Forms & Applications

Use ADOBE Reader to print the following forms and applications

Categories: | Application for Health Services | Health Facility Licensure & Certification | Food & Lodging Establishment Licensure |
| Public Health Laboratory Services | Vaccine Providers | Vital Records Orders |

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Application for Health Services

• Children's Special Health Services
  • Family income worksheet
  • Patient registration
• Family Planning
  • Client information and informed consent; Español
  • Combined hormone consent (oral contraceptive & contraceptive patch)
  • Waiver for combined hormonal contraceptive users with increased risk
  • Deferred examination consent
  • Diaphragm consent
  • IUD Consent
  • Request for IUD by women with high risk factors
  • Consent for IUD removal
  • Depo-Provera consent
  • Consent for Depo-Provera more than 13 weeks after prior injection
  • Informed consent for clients choosing Depo-Provera beyond two years
  • Mini pills (progestin-only) consent
  • Non-prescription method consent
  • Norplant removal consent
  • Medical history
• Women, Infants and Children (WIC) Program
  • Family income card
  • Request for Approval of Special (Non-Contract) Formula & Medical Nutritional Products

Health Facilities Licensure & Certification

• Application for adult foster care license
• Application for ambulatory surgical center license
• Application for assisted living center license; optional services & medication administration
• Application for chemical dependency treatment center license
• Application for hospice license
• Application for hospital license
• Application for a nursing facility license
• Application for license of radiation machine (ionizing)
• Controlled substance registration application for physicians
• Controlled substance registration application for mid-level providers
• Controlled substance registration application for non-practitioners
• Staffing exception forms - assisted living centers

Food & Lodging Establishment Licensure
New food services, lodging establishments or campgrounds seeking licensure must submit plan review questionnaire, license application, and construction plans 30 days prior to construction.

• Application for food service, lodging or campground license
• Application for temporary food service
• Food service plan review questionnaire
• Mobile food service plan review questionnaire
• Lodging establishment plan review questionnaire
• Campground plan review questionnaire
• Pool or spa plan review questionnaire
• File a complaint (submit online)

Public Health Laboratory Services

• Order sample bottle for private well testing (submit online)
• Order sample bottle for public water supply testing (submit online)
• Order medical testing supplies (submit online)
• Water system chemical analyses submissions Form 112, Form 113

Vaccine Providers

• Vaccine order form for providers; submit order online
• Vaccine transfer form
• Vaccine administration report for providers
• Wasted vaccine report form
• Vaccines for Children Program, vaccine borrowing report
• Chid immunization incentives order form
• School employee certification of health
  (Department of Education site, see "Forms")

Vital Records Orders
Certified copies of birth, death, marriage & divorce records are available. Complete and submit the following forms or place an online order using your credit card.

• Application for birth record
• Application for death record
• Application for divorce record
• Application for marriage record
• Fee waiver for military
• Fee waiver for Head Start, school enrollment, baseball
• Parental consent form for minors seeking marriage license
• Bride's and groom's worksheet for marriage license application

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