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Flu Shot Appointment & Consent Form

COVID-19 Current Numbers

RESCHEDULED: The Open House & Ribbon Cutting for the new Danville Community Health Center location has been POSTPONED due to construction delays.

The new date for this event is THURSDAY, JULY 20th 

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Medical Clinic

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Knox County Community Health Center Medical Clinic Mount Vernon Ohio

 The medical clinic at the Knox County Community Health Center provides medical care for children and adults, including: 

  • Treatment of illness such as ear aches, colds, sore throats, sinus infections
  • Management of chronic disease such as diabetes
  • Physical exams for work, school and sports
  • DOT Physical
  • Well-child exams
  • Lead testing
  • Immunizations for children and adults including shots for influenza, pneumonia, hepatitis A and B and shingles
  • Women’s health including pregnancy tests and pap tests
  • Blood pressure screenings, TB testing, tetanus shots
  • Tobacco cessation treatment
  • Nutrition counseling
  • Substance abuse treatment

We have full-time nurse practitioners, nurses, medical assistants, and a doctor. 

 

Paperwork

*NOTICE: By signing your name electronically and submitting the form(s), you acknowledge your electronic signature has the same legal validity as your manual signature.

 

Intake Packet

Intake Packet: Fillable Intake Paperwork

Spanish Intake Packet - PRINT ONLY (papeleo de admisión de pacientes - IMPRIMIR SOLO): Versión en Español - todos los servicios 

 

Other Forms

Medications List: Additional Current Medications Form      Versión en español - Lista de medicamentos adicionales

Sliding Fee Scale: SFS Application      ​ Versión en español - ​Escala móvil de tarifas

Sports Physical: OHSAA Pre-Participation Physical Exam Forms  *If athlete is coming unaccompanied, PARENT/GUARDIAN needs to SIGN form before appointment 

 

Special Clinic Forms

Please bring your Special Clinic form(s) - Additional intake forms are NOT needed. 

COVID-19 Vaccine: COVID-19 Consent Form

Flu Shot: Flu Shot Consent Form     

School Vaccines: School Immunization Clinic Consent & Demographics Forms

 

Payment Policy

  • Payment is due at time of service.
  • Minimum payment for self-pay patients is $20 for Medical.
  • If patients do not have health insurance, a sliding fee schedule at 200% above federal poverty guidelines is offered to all patients who are eligible. Need help getting coverage? Visit HealthCare.gov for easy steps to get health insurance. 
  • Health Center staff can also assist patients with enrolling in health insurance or Medicaid if they qualify.
  • Patients are expected to pay the full sliding-fee-scale amount at the time of their appointment.
  • At the time your appointment is made, you will be told how much you can expect to pay. If for some reason we need to do a procedure that was not planned, and you cannot pay in full, a statement will be given to you. The remaining balance will need to be paid before another appointment can be scheduled.
  • KCCHC protects its patients from surprise medical bills for services and items provided by KCCHC through a combination of:
    • compliance with requirements established under Section 330 of the Public Health Service Act and
    • provision of Good Faith Estimates as outlined in Section 27966B-6 of the Federal No Surprises Act. 

 

Appointments and Cancellations

  • If you cannot make a scheduled appointment, please notify us by phone, at least 24 hrs. in advance of the appointment. There is usually a waiting list of people needing an appointment, so if you can’t make yours, we would like to be able to offer the appointment time to someone else.
  • If you do not call 24 hrs. in advance to cancel an appointment, it will be considered a “missed” appointment and could delay or prohibit future appointments.
  • A missed appointment is any appointment in which the patient does not show up or call in advance to cancel or reschedule the appointment.

 

Knox County Community Health Center is a Health Center Program grantee under 42 U.S.C. 254b, and deemed Public Health Service employee under 42 U.S.C. 233(g)-(n). 

 

Notice of Privacy Practices - HIPAA

Sliding Fee Scale Chart

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Patient Satisfaction Survey

We value the experience of all our patients. Please complete this survey about your visit to help us continue to serve you in the best way possible.

Thank you!

SURVEY

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Our Medical Staff

Jennie and Jackie

Nurse Practitioner Jennie McClain 

Contact the Medical Clinics

Health Center Locations

11660 Upper Ghilchrist Rd. in Mount Vernon (Located in Knox Public Health)

206 South Mulberry Street, Mount Vernon (Moore Family Practice)

207 West High Street, Mount Vernon (Walk-In Clinic: Located in Foster's Pharmacy)

16 East Main Street in Danville (Located beside Conway's Pharmacy)

All Health Center Locations

Health Center Hours 

Monday- Friday, 8:00am - 4:30pm

Moore Family Practice: closes at 2 pm on Friday

For an appointment at either location, call 740-399-8008

healthcenter@knoxhealth.com

Or by FAX, 740-399-8012

 After-hour needs or to speak with service provider, call 740-399-8008 and select the "After Hours" option

ATTN. PROVIDERS - do not send patient records by email 

We Are Public Health

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Public Health: prevent. promote. protect

Our Mission
We are committed to the health of the community by promoting healthy lifestyles, preventing illness, and protecting the community.

Our Vision
To continue to be a leader in public health by addressing community issues through proactive and innovative solutions so that all residents may experience optimal health and a safe environment.

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Contact Us

Health Department 

Hours: Monday- Friday 8:00am - 4:30pm

Phone: 740-392-2200  Fax: 740-392-9613

11660 Upper Gilchrist Road, Mount Vernon

 KnoxHealth.com 

 

Health Center

Hours: Monday - Friday, 8:00am - 4:30pm 

Phone: 740-399-8008  Fax: 740-399-8012

11660 Upper Gilchrist Road, Mount Vernon (inside KPH) - Counseling, Dental & Medical Services

206 South Mulberry Street, Mount Vernon - Counseling & Medical Services (closes at 2 pm on Fri.)

207 West High Street, Mount Vernon (inside Foster's Pharmacy) - Medical Services

16 East Main Street, Danville - Counseling & Medical Services

706 South Market Street, Danville - Dental Services (*Temporary Hours HERE*)

 

For Health Center service during non-business hours, call 740-399-8008 and choose the "After Hours Service" option. 

For Public Health emergencies during non-business hours, call 740-397-3333 Option 1.

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