COVID-19 Vaccine Registration Form

COVID-19 Vaccine Registration Form

Any information you submit via this HIPAA compliant form is encrypted, kept strictly confidential, and will be used only for the purposes of determining vaccine eligibility and scheduling.
Today's Date
Demographics
Name *

First Name Last Name
Email Address *
Date of Birth *

Month Day Year
PLEASE NOTE: If you are not already a patient of Refuah, you must also register as a new patient here https://refuahhealth.org/new2refuah/ before you can be scheduled.
Best phone number to reach you *
Please enter a valid phone number.
Proof of Eligibility - To receive the COVID-19 vaccine in New York State you must provide proof that you live, work, or study in NY.

Acceptable forms of proof include driver's license, paystub, letter from employer or school demonstrating New York state address.
Which of the following NYS priority 1A,1B, or 1C groups currently apply to you? *

1A, Active medical, dental, or behavioral healthcare worker/student with direct patient contact 1A, Active EMS, pharmacy, or public health department worker with direct contact to patients or lab specimens 1A, Staff or resident of nursing home, skilled nursing or congregate living, adult care facility, or shelter 1A, Medical examiner, coroner, funeral worker with direct contact with infectious material and bodily fluids 1A, Home care aide, hospice worker, NYS certified personal care aide with current direct patient contact 1B, Active police, firefighter, public-facing government employee, building service or municipal transit worker 1B, Education worker (pre-K through 12), licensed registered childcare provider, in-person college instructor, schoolbus driver 1B, Public-facing 501(c)(3) non-profit worker (Note: Signed letter from agency specifying 501(c)(3) status must be uploaded as backup) 1B, Public-facing hotel, grocery store, or restaurant worker/delivery service 1B, Aged 16 and up 1C, High Risk Condition - Pregnancy 1C, High Risk Condition - Cancer (current or in remission, including 9/11-related cancers) 1C, High Risk Condition - Pulmonary Disease, including but not limited to, COPD (chronic obstructive pulmonary disease), asthma (moderate-to-severe), pulmonary fibrosis, cystic fibrosis, and 9/11 related pulmonary diseases 1C, High Risk Condition -Type 1 or 2 diabetes mellitus 1C, High Risk Condition -Heart conditions, including but not limited to heart failure, coronary artery disease, cardiomyopathies, or hypertension (high blood pressure) 1C, High Risk Condition - Severe Obesity (BMI 40 kg/m2), Obesity (body mass index [BMI] of 30 kg/m2 or higher but < 40 kg/m2) 1C, High Risk Condition - Chronic kidney disease 1C, High Risk Condition - Immunocompromised state including but not limited to solid organ transplant or from blood or bone marrow transplant, immune deficiencies, HIV, use of corticosteroid or other immune weakening medicines. (Note: Individuals with autoimmune diseases are considered immunocompromised only if they are taking medications that suppress their immune system.) 1C, High Risk Condition - Cerebrovascular disease (affects blood vessels and blood supply to the brain) 1C, High Risk Condition - Neurologic conditions including but not limited to Alzheimer's Disease or dementia. (Note: Psychiatric diagnoses and migraines are not included at this time.) 1C, High Risk Condition - Intellectual and Developmental Disabilities including Down Syndrome 1C, High Risk Condition - Liver disease 1C, High Risk Condition - Sickle cell disease or Thalassemia
NY state requires that individuals provide proof of eligibility to the vaccination site. Which of the following documents are you uploading as proof of current, active occupation, high risk condition, or age? *

Employee ID card with title/credentials (for 1A and 1B only) Business card with title/credentials (for 1A and 1B only) Professional license (for 1A and 1B only) Letter from employer on letterhead specifying title/credentials and direct contact with patients or infectious matter (for 1A and 1B only) Driver's license (for age 30+ only) Passport (for age 30+ only) Birth Certificate (for age 30+ only) Doctor's letter that states induvidual's specific high risk condition (for 1C only) Medical Record that demonstrating specific high risk condition (for 1C only) Photo of medication bottle for condition with drug and patient names visible (for 1C only) I am a current Refuah patient and this diagnosis is in my chart (for 1C only) Other
Upload proof of occupation, high risk condition, or age document here. (Please ensure that your name is visible on the document) *

Cancel of
Upload proof that you live, work, or study in NY here: *

Cancel of
Clinical Screen
Are you currently sick? *

Yes (If so, wait to register until you have recovered.) No
Have you received a different vaccine within the last 2 weeks such a flu shot? *

Yes (If so, wait until 14 days have passed since the previous vaccination.) No
Have you have received COVID monoclonal antibody or plasma therapy? *

Yes (If so, If yes, please wait at least 90 days after treatment to avoid interference of antibody therapy with vaccine-induced immune responses.) No
Other
Mobile Vaccine Clinic Location (If Applicable)
Attestation
The mandatory NY State COVID-19 Vaccine Form vaccineform.health.ny.gov must be completed PRIOR to vaccination. It includes a self-attestation regarding eligibility.
By signing below, I attest that I meet current NY state eligibility criteria to receive the COVID-19 vaccine at this time, including NY state residence (or employment when applicable) and that I will complete the NY State COVID-19 Vaccine Form prior to arriving for my vaccine appointment at Refuah. *
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COVID-19 Vaccine Registration Form

Demographics

Proof of Eligibility - To receive the COVID-19 vaccine in New York State you must provide proof that you live, work, or study in NY.

Clinical Screen

Other

Attestation