COVID-19 Vaccine Registration: Wilcrest Clinic

COVID-19 VACCINE REGISTRATION

Ibn Sina Foundation is providing COVID vaccines as per the guidelines set by Department of State Health Services, Texas to eligible members. Please select the appointment time. The vaccines will be administered Ibn Sina Children Clinic located at 11220 South Wilcrest Dr. Houston TX, 77099.
Name*

First NameMiddle NameLast Name
Mother's Information*

Mother's NameMaiden Name
Date of Birth*

MonthDayYear
Sex*
Race*
Ethnicity*
Address:

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Contact Number:*
E-mail*
example@example.com
Do you consider yourself any of the following?*

Healthcare WorkerEmergency First/Last ResponderSchool Teacher16 and upNone of the above
Do you have any known underlying health conditions such as diabetes, hypertension, obesity, thyroid disorder, cancer, or kidney, heart or lung disease?*

YesNo
Appointment*
Have you had, in the last 10 days, fever, chills, cough, shortness of breath, fatigue, muscle or body aches, headache, new loss of taste or smell, sore throat, congestion or runny nose, nausea, vomiting, or diarrhea?*

YesNo
Do you have a weakened immune system caused by something such as HIV infection or cancer or do you take immunosuppressive drugs or therapies?*

YesNo
Do you have a bleeding disorder or are you taking a blood thinner?*

YesNo
Are you allergic to any medications, food, vaccine, or latex?*

YesNo
Are you pregnant or breastfeeding?*

YesNo
Have you received passive antibody therapy (monoclonal antibodies or convalescent serum) as treatment for COVID-19?*

YesNo
Have you received any other vaccine in the last 14 days?*

YesNo
In the past two weeks, have you tested positive for COVID-19?*

YesNo
Do you have health insurance?*

YesNo
I confirm that the above information is true to the best of my knowledge and understanding. If qualified, I authorize Ibn Sina Foundation to bill my insurance company and release of information required to process my claims.?*

YesNo
Upload Picture of Your ID*

Driver's License or State Issued ID
Cancelof
Upload Picture of Your Insurance Card

Cancelof
Consent for Registration and Release of Immunization Records to Authorized Persons / Entities
I understand that, by granting the consent below, I am authorizing release of my immunization information to DSHS and I further understand that DSHS will include this information in the Texas Immunization Registry. Once in ImmTrac2, my immunization information may by law be accessed by: a Texas physician, or other health care provider legally authorized to administer vaccines, for treatment of the individual as a patient; a Texas school in which the individual is enrolled; a Texas public health district or local health department, for public health purposes within their areas of jurisdiction; a state agency having legal custody of the individual; a payor, currently authorized by the Texas Department of Insurance to operate in Texas for immunization records relating to the specific individual covered under the payor’s policy. I understand that I may withdraw this consent at any time.*

I agree
Consent for Retention of Disaster-Related Information and Release of Information to Authorized Entities
I understand that, by granting the consent below, I am authorizing retention of my (or my child’s) disaster-related information by DSHS beyond the 5 year retention period. I further understand that DSHS will include this information in the state’s central immunization registry (“ImmTrac2”). Once in ImmTrac2, my (or my child’s) disaster-related information may by law be accessed by: • a state agency, for the purpose of aiding and coordinating communicable disease prevention and control efforts, and / or • a physician or other health-care provider legally authorized to administer immunizations, antivirals, and other medications, for treating the client as a patient; I understand that I may withdraw this consent to retain information in the ImmTrac2 Registry beyond the 5 year retention period and my consent to release information from the Registry, at any time by written communication to the Texas Department of State Health Services, ImmTrac2 Group – MC 1946, P. O. Box 149347, Austin, Texas 78714-9347.*

I agree
Sorry, you do not meet the criteria for the COVID-19 vaccine at this time. Please keep checking from time to time to see if the criteria changes in future.
Consent for Scheduling the Second Dose
I agree to get myself scheduled for the second dose from Ibn Sina Clinic. I understand that the Pfizer and Moderna second doses will be 21 days and 28 days respectively from the administration of the first dose.*

I agree
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COVID-19 VACCINE REGISTRATION