Covid-19 Vaccination Form

Covid-19 Vaccination Form
For the safety of other customers and our employees, let's first get these familiar questions out of the way. Please answer this brief COVID-19 questionnaire for the person being scheduled. Please note that Choices for Children is currently only administering the Moderna Vaccine.

All fields are required.
How did you hear about us ?*
If other please list here :
In the past 14 days, have you tested positive for COVID-19?*

YesNo
In the past 14 days, have you been in close contact with anyone who tested positive for COVID-19?*

YesNo
Do you currently have fever, chills, cough, shortness of breath, difficulty breathing, fatigue, muscle or body aches, headache, new loss of taste or smell, sore throat, nausea, vomiting, ordiarrhea?*

YesNo

Tell Us What You Need

Depending on the manufacturer, the COVID-19 vaccine can require either one dose or two doses (MODERNA ONLY). Tell us if you need to start vaccination, or if you only need to schedule a second dose because you've already received the first dose somewhere else.
What do you need? (required)*

I need to start vaccination.I only need to schedule a second dose.

Determine Eligibility

First, let's make sure you're eligible to receive the COVID-19 vaccine at this time. Please provide accurate info. Your responses help us quickly serve those at highest risk. Please provide accurate info for the person being vaccinated.
Your state eligibility is open to anyone age 18 or over

Age will be used to determine which vaccine(s) patients are eligible for.

Please be ready to verify once you get to our clinic.
What is your age? (If scheduling someone else, indicate their age)*
Enter numbers only
Which group applies?*

Teachers and staff in PreK-12 Schools, childcare centers, Head Start, Part C Intervention & licensed home visitorsAll others age 18 and over
Please confirm that you have answered the statements above truthfully.*

I affirm that I have answered these questions truthfully and to the best of my knowledge and acknowledge that I may be asked to verify my eligibility information at my appointment. I also affirm that I will only book an appointment in the state for which I have answered these eligibility questions.

Please provide details

We want to help you spend less time in person, so let's take care of intake details now. We'll ask for your insurance card(s), Social Security number and/or driver's license. All fields are required, unless marked optional.
Patient information
Name*

First NameLast Name
Date of Birth *
Enter without slashes: MMDDYYYY Age restrictions may vary depending on state and/or vaccine.
Sex assigned at birth*

FemaleMale
How do we use this?

Patient birth sex is an important piece of biologic inforamtion that we use to make sure you get the care that is best for you.
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Contact Information

Contact info will be added to your patient record.
Email*
example@example.com
Phone Number*
Please enter a valid phone number.
Please see the Choices for Children and Family Notice of Privacy Practices for more information about how we may use and disclose your Protected Health Information.

By providing your mobile number and e-mail address, you consent to receive a copy of your immunization record as well as other PHI related to the vaccine sent by unencrypted email as well as live or automated calls, text messages and e-mails about this and follow-up visits, insurance and related account information and agree to the Terms of Use and Privacy Policy. Please be aware that e-mail is not a secure method of communication. This means that by choosing to receive protected health information via e-mail, you are accepting the risk that some protected health information could be acquired by someone other than you. If you do not wish to accept this risk, you may call our clinic to schedule your appointment.

By providing your mobile number, you consent to receive live or automated calls and text messages about this and follow-up visits, insurance and related account information.

We collect data regarding your activity on our webpages throughout your browsing session (“session data”) solely for purposes of our own internal analytics and improving your user experience and our products and services. We share your session data with third party service providers for these same

How to schedule COVID-19 vaccine

You can't choose the COVID-19 vaccine you receive. It'll be determined by what inventory is available in your area.
One-dose vaccine:
During this session, you'll schedule one appointment date within a range of available dates. The dose will be a complete vaccine.

Two-dose vaccine:
During this session, you'll schedule two separate appointments. The timing of both equally important doses is recommended by medical experts. The date of your second visit will be determined by the date of your first visit. The second dose is mandatory for vaccination completion.

You may need:
The vaccines are no cost to you, but we'll need to bill your insurance provider or the government. So grab your insurance card(s). If you don't have insurance, we'll ask for a valid Social Security number and/or a driver's license/state ID number.

Click Here to Download Vaccine Fact Sheet
Should be Empty:

Covid-19 Vaccination Form

Tell Us What You Need

Determine Eligibility

Please provide details

Patient information

Contact Information

Share Coverage Information

How to schedule COVID-19 vaccine