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Champaign Covid Vaccination Registration (Live)
We recommend using a computer for this registration process
17Questions
  • 1

    ATTENTION

    We will be closed on December 25th, 2021 and January 1st, 2022 in observation of the respective holidays. COVID-19 Vaccines will not be available for registration on December 24th or December 31st, 2021 due to shortened business hours. 

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    Pick a Date
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  • 7
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  • 8
    If you received the Pfizer-BioNTech or Moderna vaccines, you are eligible for a booster at least 6 months after completing your primary COVID-19 vaccination series. If you received the J & J, you are eligible for a booster after 2 months from your last shot. Please note: Per CDC guidelines, booster shots can be mix and matched. We cannot guarantee which booster will be available on the day of your chosen appointment.
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  • 9
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    Pick a Date
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  • 10
    Only 1 person can register for 1 two-dose vaccine per registration
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  • 11
    Persons under the age of 18 must be accompanied by their parent or guardian at their vaccine appointment.
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  • 12
    Persons under the age of 18 must be accompanied by their parent or guardian at their vaccine appointment.
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  • 13
    I understand the risks and benefits of this vaccine and ask that it be provided to my child/ward. I understand that it is common to experience reactions such as soreness and redness at the site of injection, fever, fatigue, muscle aches, and headaches in the 24-48 hours after the vaccination. I have been given the Emergency Use Authorization Fact Sheet about the Covid-19 vaccine that my child/ward will receive today.  I have had the opportunity to have my questions answered. I understand that CampusTown Urgent Care will submit my vaccination information to the state immunization registry. I understand that this is a two-dose vaccine.  I affirm that I will return for the second dose of the COVID-19 vaccine at the appropriate time. I understand it is recommended that my child/ward and I remain on site for 15 minutes after receiving this vaccine.
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  • 19
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  • 20
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  • 21
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  • 22
    Please Select
    • Please Select
    • United States
    • Afghanistan
    • Albania
    • Algeria
    • American Samoa
    • Andorra
    • Angola
    • Anguilla
    • Antigua and Barbuda
    • Argentina
    • Armenia
    • Aruba
    • Australia
    • Austria
    • Azerbaijan
    • The Bahamas
    • Bahrain
    • Bangladesh
    • Barbados
    • Belarus
    • Belgium
    • Belize
    • Benin
    • Bermuda
    • Bhutan
    • Bolivia
    • Bosnia and Herzegovina
    • Botswana
    • Brazil
    • Brunei
    • Bulgaria
    • Burkina Faso
    • Burundi
    • Cambodia
    • Cameroon
    • Canada
    • Cape Verde
    • Cayman Islands
    • Central African Republic
    • Chad
    • Chile
    • China
    • Christmas Island
    • Cocos (Keeling) Islands
    • Colombia
    • Comoros
    • Congo
    • Cook Islands
    • Costa Rica
    • Cote d'Ivoire
    • Croatia
    • Cuba
    • Curaçao
    • Cyprus
    • Czech Republic
    • Democratic Republic of the Congo
    • Denmark
    • Djibouti
    • Dominica
    • Dominican Republic
    • Ecuador
    • Egypt
    • El Salvador
    • Equatorial Guinea
    • Eritrea
    • Estonia
    • Ethiopia
    • Falkland Islands
    • Faroe Islands
    • Fiji
    • Finland
    • France
    • French Polynesia
    • Gabon
    • The Gambia
    • Georgia
    • Germany
    • Ghana
    • Gibraltar
    • Greece
    • Greenland
    • Grenada
    • Guadeloupe
    • Guam
    • Guatemala
    • Guernsey
    • Guinea
    • Guinea-Bissau
    • Guyana
    • Haiti
    • Honduras
    • Hong Kong
    • Hungary
    • Iceland
    • India
    • Indonesia
    • Iran
    • Iraq
    • Ireland
    • Israel
    • Italy
    • Jamaica
    • Japan
    • Jersey
    • Jordan
    • Kazakhstan
    • Kenya
    • Kiribati
    • North Korea
    • South Korea
    • Kosovo
    • Kuwait
    • Kyrgyzstan
    • Laos
    • Latvia
    • Lebanon
    • Lesotho
    • Liberia
    • Libya
    • Liechtenstein
    • Lithuania
    • Luxembourg
    • Macau
    • Macedonia
    • Madagascar
    • Malawi
    • Malaysia
    • Maldives
    • Mali
    • Malta
    • Marshall Islands
    • Martinique
    • Mauritania
    • Mauritius
    • Mayotte
    • Mexico
    • Micronesia
    • Moldova
    • Monaco
    • Mongolia
    • Montenegro
    • Montserrat
    • Morocco
    • Mozambique
    • Myanmar
    • Nagorno-Karabakh
    • Namibia
    • Nauru
    • Nepal
    • Netherlands
    • Netherlands Antilles
    • New Caledonia
    • New Zealand
    • Nicaragua
    • Niger
    • Nigeria
    • Niue
    • Norfolk Island
    • Turkish Republic of Northern Cyprus
    • Northern Mariana
    • Norway
    • Oman
    • Pakistan
    • Palau
    • Palestine
    • Panama
    • Papua New Guinea
    • Paraguay
    • Peru
    • Philippines
    • Pitcairn Islands
    • Poland
    • Portugal
    • Puerto Rico
    • Qatar
    • Republic of the Congo
    • Romania
    • Russia
    • Rwanda
    • Saint Barthelemy
    • Saint Helena
    • Saint Kitts and Nevis
    • Saint Lucia
    • Saint Martin
    • Saint Pierre and Miquelon
    • Saint Vincent and the Grenadines
    • Samoa
    • San Marino
    • Sao Tome and Principe
    • Saudi Arabia
    • Senegal
    • Serbia
    • Seychelles
    • Sierra Leone
    • Singapore
    • Slovakia
    • Slovenia
    • Solomon Islands
    • Somalia
    • Somaliland
    • South Africa
    • South Ossetia
    • South Sudan
    • Spain
    • Sri Lanka
    • Sudan
    • Suriname
    • Svalbard
    • eSwatini
    • Sweden
    • Switzerland
    • Syria
    • Taiwan
    • Tajikistan
    • Tanzania
    • Thailand
    • Timor-Leste
    • Togo
    • Tokelau
    • Tonga
    • Transnistria Pridnestrovie
    • Trinidad and Tobago
    • Tristan da Cunha
    • Tunisia
    • Turkey
    • Turkmenistan
    • Turks and Caicos Islands
    • Tuvalu
    • Uganda
    • Ukraine
    • United Arab Emirates
    • United Kingdom
    • Uruguay
    • Uzbekistan
    • Vanuatu
    • Vatican City
    • Venezuela
    • Vietnam
    • British Virgin Islands
    • Isle of Man
    • US Virgin Islands
    • Wallis and Futuna
    • Western Sahara
    • Yemen
    • Zambia
    • Zimbabwe
    • Other
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  • 23
    If you have insurance, we cannot process your COVID-19 Vaccine if you do not provide your insurance information.
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  • 24
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  • 25
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  • 26
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  • 27

    Enter your insurance card information exactly how it appears on your insurance card. We cannot process your test if your insurance information is not accurate.

    Policy Holder Name       
    Member ID or Subscriber ID             
    Group Number     
    Policy Holder's Birth Date           
    Claims Mailing Address         
    Insurance Carrier        

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  • 28
    We cannot process your COVID vaccination if you do not provide pictures of your insurance card
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  • 29
    We cannot process your COVID vaccination if you do not provide pictures of your insurance card
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  • 30
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  • 31
    ATTENTION: If you have any questions regarding vaccine availability, please contact us.
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  • 32
    Per CDC guidelines, booster shots can be mix and matched. We cannot guarantee which booster will be available on the day of your chosen appointment. If you have a preference, please call ahead to verify booster availability.
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  • 33
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  • 36
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  • 37
    This registration form is not currently supported on mobile devices. Please use a desktop or laptop computer to register
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  • 38
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  • 39
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  • 40
    I understand the risks and benefits of this vaccine and ask that it be provided to me. I understand that it is common to experience reactions like soreness and redness at the site of injection, fever, fatigue, muscle aches, and headaches in the 24-48 hours after vaccination I have been given the Emergency Use Authorization Fact Sheet about the Covid-19 vaccine that I will receive today.  I have had the opportunity to have my questions answered. I understand that CampusTown Urgent Care will submit my vaccination information to the state immunization registry. I understand that this is a two-dose vaccine.  I affirm that I will return for the second dose of the COVID-19 vaccine at the appropriate time. I understand it is recommended that I remain on site for 15 minutes after receiving this vaccine.
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