Forms
Sterilization – Instructions for Request and Consent Forms
Family Planning - Form
October 13, 2022
Sterilization – Instructions for Request and Consent Forms
Language Identification Flashcard
Family Planning - Form
October 13, 2022
Language Identification Flashcard
Contraceptive Spermicide (Film and Gel) – Counseling Handout
Family Planning - Form
October 12, 2022
Contraceptive Spermicide (Film and Gel) – Counseling Handout
Contraceptive Spermicide (Film and Gel) – Instructions
Family Planning - Form
October 12, 2022
Contraceptive Spermicide (Film and Gel) – Instructions
Contraceptive Implant – Consent Form
Family Planning - Form
October 11, 2022
Contraceptive Implant – Consent Form
Contraceptive Implant – Counseling Handout
Family Planning - Form
October 11, 2022
Contraceptive Implant – Counseling Handout
Birth Control Pills COCs – Counseling Handout
Family Planning - Form
October 11, 2022
Birth Control Pills COCs – Counseling Handout
COVID-19 Vaccine Troubleshooting Report
Immunization - Form
August 24, 2022
COVID-19 Vaccine Troubleshooting Report
NM J-1 Waiver Application 2024
Primary Care & Rural Health - Form
August 17, 2022
The New Mexico J-1 waiver program allows foreign medical graduates to obtain a waiver of their 2 year foreign residence requirement in exchange for a commitment to practice in underserved areas of New Mexico after the completion of their training.
VFC School Immunization Consent Form
Immunization - Form
August 17, 2022
This is the form to be completed by parents or guardians indicating whether or not a child is to be vaccinated at school.
VFC Vaccine Administration Form (Part B)
Immunization - Form
August 17, 2022
This form allows you to provide immunization information for entry into NMSIIS.
Hepatitis B Immune Globulin (HBIG) Reporting Form
Perinatal Hepatitis B Prevention - Form
August 9, 2022
Please complete this information on every newborn receiving hepatitis B immune globulin (HBIG).
CDC-Revised document as COVID-19 Vaccine Program Provider Agreement
Immunization - Form
May 18, 2022
CDC-Revised document as COVID-19 Vaccine Program Provider Agreement
CDC-Supplemental document as COVID-19 Vaccine Redistribution Agreement
Immunization - Form
May 18, 2022
CDC-Supplemental document as COVID-19 Vaccine Redistribution Agreement
Turquoise Lodge Authorization to Disclose Health Information Form
Turquoise Lodge Hospital - Form
May 18, 2022
This form should be used to authorize the disclosure of health information for patients.
PHD Assignment of Benefits and Consent Form
Family Planning - Form
April 14, 2022
Assignment of Benefits and Consent Form
COVID-19 In-Person Visitation Application
Health Improvement - Form
March 7, 2022
COVID-19 In-Person Visitation Application
COVID-19 In-Person Visitation Application Template
COVID-19 In-Person Visitation Application FAQ
Birthing Workforce Retention Fund Application Form
Certified Nurse Midwives and Licensed Midwives - Form
February 18, 2022
Use this form to provide birthing workforce retention fund information to the New Mexico Department of Health.