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Vaccine Clinic Registration form
Columbia City Library~ Wednesday, August 21st, 2024~ 4pm-7pm
COVID VACCINES, ROUTINE CHILDHOOD VACCINES AVAILABLE FOR CHILDREN 0-18 YEARS. NO INSURANCE NECESSARY.
Columbia City Library
4721 Rainier Ave S., Seattle, WA 98118
Patient's Name
First Name
Last Name
Birth Date
Please select a month
January
February
March
April
May
June
July
August
September
October
November
December
Month
Please select a day
1
2
3
4
5
6
7
8
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10
11
12
13
14
15
16
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18
19
20
21
22
23
24
25
26
27
28
29
30
31
Day
Please select a year
2024
2023
2022
2021
2020
2019
2018
2017
2016
2015
2014
2013
2012
2011
2010
2009
2008
2007
2006
2005
2004
2003
2002
2001
2000
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1997
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1933
1932
1931
1930
1929
1928
1927
1926
1925
1924
1923
1922
1921
1920
Year
Sex
Male
Female
Gender Identity
Male
Female
Non-Binary
Other
Parent/Caregiver's Name
Relationship to the patient
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Email Address
Phone Number
Racial Identity
White
Black
Asian
Native Hawaiian or Pacific Islander
American Indian/Alaska Native
Other
Ethnicity
Hispanic/Latino
Not Hispanic/Latino
Insurance Provider *INSURANCE IS NOT REQUIRED*
Premera
Regence BCBS
Aetna
Cigna
Kaiser
First Choice Health Network
Molina Apple Health
ProviderOne or Other Apple Health Plan
Other
Insurance ID Number
Insurance Group Number
Insurance Subscriber
Subscriber Date of Birth
-
Month
-
Day
Year
Date
Subscriber Relationship to Patient
Picture of Insurance Card
Browse Files
Drag and drop files here
Choose a file
Cancel
of
I give consent for my child to receive:
All required and recommended childhood vaccines
COVID Vaccine
Annual Flu Vaccine
Only specific vaccines (please specify below)
Other Information
Signature
Submit Form
Submit Form
Should be Empty: