Name
Social Security Number
Date of Birth
Gender MaleFemale
Email
Name of Facility/Residence
Address
Street Address Line 2
City
State
Zip Code
Race HispanicAsianBlack or African AmericanCaucasianPacific IslanderAmerican Indian [cf7mls_step cf7mls_step-1 "Next" ""]
Your insurance will be charged for the costs of administering your vaccination. If you have Medicare insurance, please provide your red, white and blue Medicare card.
Insurance Company
Medicare/Insurance ID Number
Policy Holder First Name
Policy Holder Last Name
Policy Holder Date of Birth
Policy Holder Relationship to Client
Upload the FRONT of your insurance card (e.g. red, white & blue Medicare card)
Upload the BACK of your insurance card
COVID-19 Vaccine Fact Sheet - Pfizer
Click here to review the Pfizer COVID-19 Fact Sheet:
VACCINE INFORMATION FACT SHEET
COVID-19 Vaccine Fact Sheet - Moderna
Click here to review the Moderna COVID-19 Fact Sheet:
Check all vaccines that you require: Pfizer BoosterModerna BoosterFluShingles - for ages 50+ (Shingrix)Pneumonia - for ages 65+ or 19-64 with chronic conditions e.g. COPD, diabetes, heart disease (Pneumovax)
Which arm do you prefer for the vaccine? RightLeft
Do you have any of the following chronic health conditions? YesNoI don't know
Cancer
Chronic Kidney Disease
COPD (Chronic Obstructive pulmonary disease)
Heart conditions, such as heart failure, coronary artery disease, or cardiomyopathies
Immunocompromised state (weakened immune system) from solid organ transplant
Obesity (body mass index [BMI] of 30 kg/m2 or higher but < 40 kg/m2)
Severe Obesity (BMT >= 40 kg/m2)
Pregnancy
Sickle Cell disease
Smoking
Type 2 diabetes mellitus
Have you had a severe allergic reaction (e.g., anaphylaxis) to a COVID-19 vaccine, a component of the COVID-19 vaccine (including polyethylene glycol (PEG), which is found in some medications, such as laxatives and preparations for colonoscopy procedures) or Polysorbate? YesNoI don't know
Have you had a severe allergic reaction (e.g. anaphylaxis) to another vaccine (notor any other injectable medication? YesNoI don't know
Do you have a weakened immune system caused by something such as HIV infection or cancer or do you take immunosuppressive drugs or therapies? YesNoI don't know
Do you have a fever YesNo
Are you feeling sick? YesNo
Are you pregnant or breastfeeding? YesNo
Have you received passive antibody therapy (monoclonal antibodies or convalescent serum) as treatment for COVID-19? YesNo
Have you had a positive test for COVID-19 in the past 10 days? YesNo
Please select a time for your appointment
Appointment Time (Write between 2PM - 3PM)
Required Documentation for Vaccination Appointments
You will need to show proof of identity at your appointment. Examples include:
Driver’s license
California ID card or REAL ID card (from the DMV)
Military ID
Passport
**If you are attending for your second or third dose, please bring your white vaccine record card AND a photo ID.**
By clicking the submit button, I agree to terms & conditions.
I attest that the above information is true and correct to the best of my knowledge. I hereby give my consent to the licensed healthcare provider administering the vaccine, as applicable, to share my personal, demographic and health condition information in order to provide me with vaccination services for the COVID-19 vaccine.
If filling form on behalf of patient, please type your name and relationship to patient.
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