COVID19 vaccination form

Requesting for COVID-19 vaccination

Fill the form below and we will get back to you as soon as possible.
Full Name *
First name Middle initial Last name
Date of Birth *

Day Month Year
Age *
Weight (lbs) *
Profession
Gender *

Male Female
Ethnicity *
Race *
Phone Number *

Area Code Phone Number
Address *

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code Country
E-mail Address *
Have you been seen as a patient at our facilities *

Yes No
Vaccination requested: *

first dose (age 12 & above) second dose (age 12 & above) third dose for immunocompromise status Pfizer booster dose (age 18 & above)
Date of last COVID19 vaccination

Month Day Year
Date
Upload the front of your vaccine card

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Cancel of
Upload an image of your driver license or ID card *

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Cancel of
Upload the front image of your Medicare or insurance card *

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Your Medicare or insurance carrier may be billed for any fee associated with COVID-19 vaccination such as televisit, counseling, administration, and treatment of anaphylactic reaction. There is no charge directly to patients for the COVID-19 vaccination and you will not be billed for any balances for the above services. There is also no out of pocket cost for uninsured patients. Cancel of
Upload the back image of your insurance card *

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Cancel of
I am uninsured
CDC What To Expect After Vaccine & V-safe - print for reference
Fillable CDC Prevaccination Screening Form - Please complete, save a copy to your desktop or phone, then upload below.
Upload signed CDC Prevaccination Screening Form *

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Cancel of
Do you have one of the following health conditions
I am requesting for a televisit prior to vaccination
Fillable Vaccine Consent Form - Please complete, save a copy to your desktop or phone, and then upload below.
Upload signed consent form *

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Cancel of
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Requesting for COVID-19 vaccination