Forms
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
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
Still Birth Record Search Application
Vital Records - Form
February 26, 2020
Use this form to request a still birth certificate.
Water Analysis Request Form
Biology - Form
February 19, 2020
Use this form to request water sample analysis.
VFC Transport Temperature Log Form for Refrigerated Vaccines
Immunization - Form
February 14, 2020
Complete this log when transporting vaccines to an alternate or back-up refrigerator, or when transferring to another provider.
VFC Emergency Vaccine Management Plan
Immunization - Form
November 22, 2019
The New Mexico VFC Program requires each practice to develop and maintain an Emergency Vaccine Management Plan. Properly completing this template will meet the VFC Program requirement to have a written plan for storage and handling procedures in an emergency.
VFC Routine Vaccine Management Plan
Immunization - Form
November 22, 2019
The New Mexico VFC Program requires each practice to develop and maintain a Routine Vaccine Management Plan. Properly completing this template will meet the VFC Program requirement for VFC Program participants to have written vaccine storage and handling plans.
Request to Change Gender Designation on a Birth Certificate: Adult Form
Vital Records - Form
October 28, 2019
This form allows an adult to request a gender designation change on their own birth certificate.
Request to Change Gender Designation on a Birth Certificate: Parent/Legal Guardian Form
Vital Records - Form
October 28, 2019
This form allows the legal parent/guardian to request a gender designation change on their child's birth certificate.
Request to Change Gender Designation on a Birth Certificate: Two Parent Signature Form
Vital Records - Form
October 28, 2019
This form allows parents to request a gender designation change on their child's birth certificate.
Request to Change Gender Designation on a Birth Certificate: 14 Years of Age or Over Consent Form
Vital Records - Form
October 28, 2019
This additional form is required to request a gender change on a birth certificate if the registrant is 40 years of age or over.
Authorization to Disclose Health Information (English)
Security Office - Form
October 8, 2019
This authorization allows the Department of Health (DOH) to disclose confidential health information about you. The authorization may be revoked. It will remain in effect for six (6) months unless a different time is stated. You are entitled to a copy of the completed authorization. There may be fees charged for any copying associated with this request. If you are a person with a disability and you require this authorization in an alternative format or require a special accommodation to complete this form, you may request assistance from staff at any DOH location or from the DOH Chief Privacy Officer.
STD Case Reporting Form
Sexually Transmitted Diseases - Form
September 25, 2019
All STD cases diagnosed or treated in New Mexico are required by law to be reported to the STD Program in Santa Fe. Additionally, any medical laboratory anywhere in the United States performing testing for New Mexico must report positive results to the New Mexico STD Program in Santa Fe.
Prefilled Specimen Submission Form for norovirus testing (raw stool)
Norovirus - Form
September 9, 2019
Prefilled Specimen Submission Form for norovirus testing (raw stool)
Prefilled Specimen Submission Form for enteric bacteria testing (transport media)
Norovirus - Form
September 9, 2019
Prefilled Specimen Submission Form for enteric bacteria testing (transport media)
Admission Application for New Mexico State Veterans' Home
Veterans' Home - Form
June 26, 2019
Fill out this application to apply for admission to the New Mexico State Veterans' Home.
Turquoise Lodge Adult Financial Eligibility Form
Turquoise Lodge Hospital - Form
May 10, 2019
This form should be completed to determine financial eligibility for adult patients.
Radio Frequency Interference Check - Intoxilyzer 8000
Breath Alcohol - Form
April 23, 2019
Radio Frequency Interference Check - Intoxilyzer 8000