Appointment Form V2

Covid-19 Vaccine Appointment (Form V2)

To schedule an appointment, please fill out the information below.
Contact Information
First name *
Last name *
Address *

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Phone number *
Include area code
Email address *
Appointment Details
Please select an appointment time *
Requirements *

I understand that there is no cost for the vaccine but I must bring one of the following:
• For 65+ on medicare (or under 65 - disability): need the Medicare Part A & B card (red, white & blue - says hospital, medical on it)

• Medicaid ID#

• Commercial Insurance or Healthcare Marketplace insurance card: need BIN, PCN, ID, and group number

• Uninsured: need Social Security Number or Drivers License Number
Requirements *

I understand I will be required to wait 15 minutes after receiving my vaccination.
Location and Appointment *

I understand that I am making a commitment to come to the vaccination appointment, located at The Orchard Church, 3903 Voice Road, Kinglsey, MI 49649
Additional Comments:
Please verify that you are human *
The vaccines will be distributed at The Orchard Church, 3903 Voice Road, Kingsley, MI 49649.

The vaccine is free of charge, but please bring your insurance card if available.
Please arrive early and wear a facemask when entering the building.

You will be required to wait fifteen minutes after receiving the vaccine.
Should be Empty:

Covid-19 Vaccine Appointment (Form V2)