1948 Wiltshire Rd. Suite 1
Kearneysville WV, 25430
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Contact Numbers
Main Phone Number:
Well & Septic Fax:

Hours of Operation
Monday Friday
8:30 am 4:30 pm
Patient Forms

Beginning in June 2016 our immunization clinic will be by appointment only. New patients will need to pre-register by submitting their intake forms, immunization records (for patients 18 and under), and a front-and-back copy of their insurance card(s) if applicable. Please choose one of the following ways to submit your information:

Mail:Jefferson County Health Department – Immunization Office
1948 Wiltshire Road, Suite 1
Kearneysville, WV, 25430
In Person: At the above address between 8:30am & 4:30pm, Monday-Friday
Fax: 304-728-3319 - Attention Immunization Office
Email: JeffersonLHD@wv.gov - patient name as subject

Vaccines for adults and children (please print this form double-sided if possible):
Immunization Intake Form

Immunizations for patients 18 and under (must bring up-to-date shot record):
Vaccines for Children Program Patient Eligibility Screening

TB tests and screening letters:
Tuberculosis Risk Assessment - English
Tuberculosis Risk Assessment - Spanish

Seasonal Influenza Vaccination Consent/Administration Form
Click here to download the form

New Family Planning patients (Medicaid patients must bring card):
Family Planning Program Basic Data

To send medical records to another healthcare provider:
Authorization to Release or Obtain PHI