Champaign Covid Vaccination Registration (Live)

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.
2
Unrequire - for staff use only
YESNO
3
Form is currently being fixed. Please check back later. * This field is required.
Huge
Large
Normal
Small
Ok
Ok
4
Sorry. We do not currently have any vaccines available. Please check back later.* This field is required.
Huge
Large
Normal
Small
Ok
Ok
5
Today's Date
6
Date Of Birth* This field is required.
Date
Month
Day
Year
7
Age of Person
8
Would you like to receive the first dose in vaccination series or a booster?* This field is required.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. If you have a preference, please call ahead to verify booster availability.
First Dose
Pfizer Booster
Moderna Booster
Janssen Booster (J&J)
9
When did you receive your last dose of the COVID-19 vaccine?* This field is required.
Date
Month
Day
Year
10
Number of persons being vaccinated. If you can not select a quantity, then we are currently out of vaccines.* This field is required.Only one person can register for an appointment at a time.
11
Number of persons being vaccinated (Limit: 1). If you can NOT select a quantity, then we are currently out of vaccines.* This field is required.Only 1 person can register for 1 two-dose vaccine per registration
12
Number of persons under 18 being vaccinated. If you cannot select a quantity, then we are currently out of vaccines. Persons under the age of 18 will receive the Pfizer-BioNTech COVID-19 Vaccine.* This field is required.Persons under the age of 18 must be accompanied by their parent or guardian at their vaccine appointment.
13
Number of persons under 12 being vaccinated. If you cannot select a quantity, then we are currently out of vaccines. Persons under 12 years of age will receive the Pfizer-BioNTech Pediatric COVID-19 Vaccine.* This field is required.Persons under the age of 18 must be accompanied by their parent or guardian at their vaccine appointment.
14
Parental Consent* This field is required.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.
Clear
15
Old - Number of persons being vaccinated. If you can Not select a quantity, then we are currently out of vaccines.* This field is required.
16
Location* This field is required.
631 E. Green St., Champaign, IL
17
Legal Full Name: (Must be like it appears on your driver's license)* This field is required.
First Name
Middle Name
Last Name
18
Gender* This field is required.
Male
Female
19
Race* This field is required.
American Indian or Alaska Native
Black or African American
Asian
Native Hawaiian or Other Pacific Islander
White
Other race or multiracial
Unknown
Prefer not to answer
20
Ethnicity* This field is required.
Hispanic or Latino
Non-Hispanic
Unknown
Prefer not to answer
21
Email* This field is required.
example@example.com
22
Phone Number* This field is required.
Area Code
Phone Number
23
Address* This field is required.
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
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
Curacao
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
Country
24
Type of Insurance (If Applicable)* This field is required.If you have insurance, we cannot process your COVID-19 Vaccine if you do not provide your insurance information.
I have Medicaid/Medicare, or other government health insurance coverage
I have Commercial Insurance
I do not have insurance. I am indigent & can provide verification.
25
Social Security Number
26
The federal government will cover the cost of the vaccine itself at this time. I understand that CampusTown Urgent Care will submit a bill to my insurance company, Medicare, Medicaid, etc, as applicable, for the administration of the vaccine. Most insurance plans are required by Federal law to cover the cost to deliver the vaccine without applying out-of-pocket responsibility to the patient. I understand that if I am uninsured, a bill will be submitted to the federal government pursuant to the Families First Coronavirus Response Act, Public Law 116-127, March 18, 2020. I will provide any necessary information to Campustown to submit its bills, including my insurance information (insured) or social security number (uninsured).
Yes, I understand
27
How would you like to enter you insurance information?
Take pictures of card
Type in insurance information
28
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    Policy Holder Name
Member ID or Subscriber ID          Member/Subscriber ID
Group Number Group Number
Policy Holder's Birth Date Policy Holder's Birth Date
Claims Mailing Address     Claims Mailing Address
Insurance Carrier     Insurance Carrier
29
Upload front of cardWe cannot process your COVID vaccination if you do not provide pictures of your insurance card
30
Upload back of cardWe cannot process your COVID vaccination if you do not provide pictures of your insurance card
31
Unrequire Appointment Selection -- Staff Only
YESNO
32
Appointment Time (First Vaccine)* This field is required.ATTENTION: Vaccine availability will be as posted here: Monday/Wednesday/Friday - Pfizer. Tuesday/Thursday - Moderna. If you have any questions regarding vaccine availability, please contact us.
33
Appointment Time (Booster) 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. ATTENTION: Booster availability will be as posted here: Monday/Wednesday/Friday - Pfizer. Tuesday/Thursday - Moderna.
34
Booster Date
Date
Year
Month
Day
35
Months Between Appointment and second dose
36
There must be 6 months between last Pfizer/Moderna Shot and the Booster Shot. Make sure that you inputted the correct date for when you received your second dose, or please come back later* This field is required.
37
There must be 2 months between last J&J shot and the Booster Shot. Make sure that you inputted the correct date for when you received your second dose, check the appointment date, or please come back later.* This field is required.
38
Appointment Time (Second Vaccine)* This field is required.This registration form is not currently supported on mobile devices. Please use a desktop or laptop computer to register
39
Confirmation
40
Verify that the following information is correct:
Huge
Large
Normal
Small
Ok
Ok
41
Consent* This field is required.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.
Clear
Should be Empty: