Forms
COVID-19 Vaccine Consent Form English
Immunization - Form
March 25, 2021
This form should be used as Consent for COVID-19 Vaccinations
COVID-19 Vaccine Consent Form Spanish.
Immunization - Form
February 25, 2021
This form should be used as Consent for COVID-19 Vaccinations
Midwife Complaint Form
Certified Nurse Midwives and Licensed Midwives - Form
January 12, 2021
Use this form to file a complaint against a midwife.
COVID-19 Vaccine Consent Form Spanish
Immunization - Form
December 18, 2020
This form should be used as Consent for COVID-19 Vaccinations
General Clinical Request Form
Scientific Laboratory - Form
December 15, 2020
SLD General Clinical Request Form v. 4.1
VFC COVID-19 Troubleshooting Record Form
Immunization - Form
December 15, 2020
This form should be used to report out of range temperature incidents and submit a troubleshooting record to the vaccines for children program.
Credentialing COVID-19 Providers Form
2019 Novel Coronavirus - Form
December 10, 2020
Credentialing COVID-19 Providers Form
EMS Local Funding Program Application Form FY22
EMS Fund Act - Form
November 6, 2020
EMS Local Funding Program Application Form
EMS Local Funding Program Annual Service Report Form FY22
EMS Fund Act - Form
November 6, 2020
EMS Local Funding Program Annual Service Report Form
EMS TSFA Trauma System Development Application FY22
EMS Committees - Form
October 13, 2020
This document describes the required process for eligible trauma system development projects to receive funding. Funding will be issued through a separate agreement between each approved organization and the New Mexico Department of Health Memorandum of Agreement process.
COVID Test Request Form
Scientific Laboratory - Form
October 9, 2020
COVID Test Request Form Prefilled
Naloxone Standing Order Prescription Hardcopy
Opioid Safety - Form
July 8, 2020
This is the document used to order Naloxone HCI Solution, Narcan Nasal Spray, or Evzio.
VFC Northeast Region Temperature Log Form
Immunization - Form
June 29, 2020
Colfax, Guadalupe, Harding, Los Alamos, Mora, Rio Arriba, San Miguel, Santa Fe, Taos, and Union
VFC Northwest Region Temperature Log Form
Immunization - Form
June 29, 2020
Cibola, McKinley, San Juan, Sandoval, Torrance, and Valencia
VFC Southeast (A) Region Temperature Log Form
Immunization - Form
June 29, 2020
Chaves, Curry, DeBaca, Lincoln, and Quay
VFC Southeast (B) Region Temperature Log Form
Immunization - Form
June 29, 2020
Eddy, Lea, Lincoln, and Roosevelt
VFC Southwest Region Temperature Log Form
Immunization - Form
June 29, 2020
Catron, Dona Ana, Grant, Hidalgo, Luna, Otero, Sierra, and Socorro
Breath Alcohol Instrument Peripheral Ordering
Breath Alcohol - Form
May 29, 2020
Breath Alcohol Instrument Peripheral Ordering
Public Health Emergency Licensing Instruction
EMS Licensing - Form
April 7, 2020
Public Health Emergency Licensing Instruction