THIS REGISTRATION FORM CAN BE COMPLETED ON A DESKTOP, TABLET OR MOBILE DEVICE

Note: At this time, we will be providing either Pfizer &  Moderna vaccines.

*Special Note: The registration form's language default is English; however, the form can be translated into 26 different languages by clicking on the upper right hand corner of the registration page and selecting the appropriate language. The form does use an auto translator, so please be advised that some fields may not be properly translated.

ABOUT Childress Nursing Services (CNS)
CNS is a WA state licensed home health agency and mobile clinical laboratory based in Renton, WA that primarily provides fertility and maternal in-home medication injections and support to clients in King, Pierce, and Snohomish counties. Our home health agency is uniquely composed exclusively of licensed nurses. We do focus on serving women from preconception to post-delivery; however, due to the need to have all hands on deck to fight the pandemic, we have decided to join in the efforts to vaccinate Washingtonians against the SARS-CoV-2 virus that causes Covid-19 by providing Covid-19 vaccine home injections.

BEFORE COMPLETING THIS REGISTRATION FORM

Number 1: You (and your household members) should have all of your questions answered about receiving a Covid-19 Vaccine BEFORE SUBMITTING YOUR REGISTRATION as time is of the essence to get as many people vaccinated as possible within the shortest time frame. You can learn more about the Covid-19 Vaccine and get all of your questions answered before registering for the CNS home vaccination service at:   https://www.doh.wa.gov/Emergencies/COVID19/VaccineInformation/FrequentlyAskedQuestions 

You can also call Washington State's COVID-19 Information Hotline: Dial 1-800-525-0127, then press #. If you can’t reach the hotline via the regular number, then use the alternate number, 888-856-5816 (a Spanish option is available). 6 a.m. to 10 p.m. Monday 6 a.m. to 6 p.m. Tuesday through Sunday, and observed state holidays. Language assistance is available. 

Number 2: You (and your household members) should have accessed and read the EUA fact sheets for each Covid-19 Vaccine manufacturer - Pfizer, Moderna and Janseen BEFORE SUBMITTING YOUR REGISTRATION by clicking the links below. 

Click here to review the Pfizer-BIONTECH COVID-19 Fact Sheet: https://www.fda.gov/media/144414/download 

Click here to review the Moderna COVID-19 Fact Sheet: https://www.fda.gov/media/144638/download 

Click here to review the Janssen COVID-19 Fact Sheet: https://www.fda.gov/media/146305/download 

1. The primary adult household member can register themselves and up to 9 additional members of the household who want to receive the Covid-19 vaccine. As specific vaccine allocation can vary, the minimum age to register at this time is 18 years old. Household members do not have to be blood relatives and can be people who frequently visit your household, like caregivers or close family/friends. We will not require proof of residency. However, household members must be available for the 2nd dose, if applicable, at the same service address to be scheduled for the 2nd dose appointment set at the scheduled date and time. 2nd dose appointments will be set at the same time as 1st dose appointments, so look at your monthly calendars and schedule accordingly.

The purpose of this household registration is to help others rejoin their social circle safely and to minimize the detrimental effects of social isolation. Households registering 5 or more individuals with at least one household member belonging to the WA state Vaccine Phase 1 through Tier 4 level will be prioritized. *See website for "Priority Booking" order. Registrants with less than 5 members will automatically be placed on the Standby/Wait List. For more details, visit our website at www.ChildressNursing.com.

2. Please do not call our office to inquire about scheduling, canceling or rescheduling an appointment. If we can accommodate your In-Home Covid-19 vaccine injection request or if we have any questions about your registration, then we will contact you either by phone or email. Please allow 1 to 2 weeks to receive a response from our office. Also, mark safe and/or check your spam folder for emails from Vaccine@ChildressNursing.com 

3. Just because you submitted a pre-registration form does not automatically mean that you will receive a CNS home vaccine appointment, as state vaccine allocation to providers vary, and our office reviews and priortizes registrations before setting and confirming home Covid-19 vaccine injection visit appointments. Households referred by state/county/city governmental agencies, community-based organizations and/or healthcare practitioners will be considered first.

4. Fill out the form as much as possible. Registrations with missing or incorrect information (especially incorrect/missing contact info with service addresses, phone numbers, and email addresses) will be placed on hold for more information and will be automatically placed at the back of the line, as time is of the essence in vaccinating as many people as possible. Trying to correct or find missing information slows down the process. So, read over the form fields carefully and answer to the best of your knowledge.

5. Health Insurance. The federal government has pre-purchased Covid-19 vaccines. The federal government and insurance companies are required to cover the costs that vaccine administration providers incur to administer the vaccine to their patients/clients. As a result, patients/clients should not receive a bill for the vaccine nor for vaccine administration. If you do receive a bill, then contact your insurance provider first to correct the error. *Note: Please have front and back copies of your insurance card ready to upload. You can take pictures from your device's camera and upload in most major formats. If you do not have health insurance, then please have a copy of your driver's license or state ID available to upload.

6. Things you will need during a vaccination home visit

• Some form of photo identification, so our nurses can properly identify the person receiving services. We will not make take photos or request copies of your ID. This can include a state ID, driver's license, passport, work ID, school ID, etc.
• If you require an interpreter/translator (all CNS nurses are fluent in English), then you will be responsible for providing an interpreter/translator and any costs associated with having that professional. Ideally, one of the household members should serve as an interpreter/translator. You can contact one of your local community organizations for interpreter/translator support.
• CNS will provide the vaccine, nurse vaccinators and supply all medical equipment and supplies needed for the home visit.
• As we know that for many people, this may be your 1st home health injection visit. Upon confirmation of your appointment, you will be provided with a "What to Expect" document and supporting materials that will provide further details about your home visit and best tips to prepare

All inquiries or problems with completing this registration form should be sent to our office email address: Vaccine@ChildressNursing.com. Please allow 1 to 2 weeks for a response.  

We are honored to be of service to you and your family!

Childress Nursing Services Team

Fields with an asterisk* are required

(This information will be used to contact you for your second dose reminder, if applicable. Please note: This phone number MUST be able to receive text messages.)

Service Address (address to which services will be delivered and must be the same for all household members listed). All household members will be scheduled for their 2nd dose, if applicable, using this service address and must be available at this service address (unless notified otherwise by the CNS office) for their 2nd dose appointment.

(Please only indicate which days of the week and time frames that your household is available within the next 2 weeks from this form’s submission date only. All household members must be available during the ENTIRE time frame. Clients with more flexible, available dates have a higher chance of being serviced early.

Last-mile Appointments are how we manage overflow to minimize vaccine wastage. A last-minute notification is posted on the CNS Facebook page: @Childress Nursing about appointments available and all household members should be at their service address and ready for vaccination within 5 – 10 minutes of notification.) We do not anticipate using this option frequently.

IMPORTANT:

*If you require a 2ⁿᵈ dose, then we will automatically schedule you according to the type of vaccine received.

• If you receive Pfizer-BIONTECH’s vaccine, you should receive a second vaccination three weeks (21 days) later or within recommended interval 17-25 days.
• If you receive Moderna's vaccine, you should receive a second vaccination four weeks (28 days) later or within recommended interval 24-32 days.
• If you receive Janssen (J&J) vaccine, you will receive one dose and not require a
second dose.

(If you or anyone else in your household have any medical conditions that put you at greater risk for an anaphylactic reaction or severely compromised medical state, then you should book your vaccination appointment at a medical clinic, as they will be more equipped to handle special medical situations and generally have extra staff on hand to assist.)

The following questions will help us determine if there is any reason you or your household member(s) should not get the COVID-19 vaccine at home. If you answer “yes” to any question, it does not necessarily mean you should not be vaccinated. It just means additional questions may be asked. If a question is not clear, please ask your primary healthcare provider to explain it.

Please answer questions ONLY for the people who are seeking to get vaccinated in your household by CNS during your available service date and times indicated on this form.

1. Have you or any household member ever had an allergic reaction to? (This would include a severe allergic reaction[e.g., anaphylaxis] that required treatment with epinephrine or EpiPen® or that caused you to go to the hospital. It wouldalso include an allergic reaction that occurred within 4 hours that caused hives, swelling, or respiratory distress, includingwheezing.) If yes, please list the name of the person(s).

(Please indicate if you and/or household member have spoken with your primary healthcare provider about any special health issue and have been recommended to proceed with vaccination. Ex. pregnant or undergoing fertility treatments, hospice care, immunocompromised, etc. *Note: We ask you for the name and contact information of your primary healthcare provider to confirm or follow-up with your provider)

I/We,

consent to any medical lab testing, injections or treatments to be provided to said minor(s)/ward(s), when such services are recommended and supervised by Childress Nursing Services, LLC or any of its affiliated clinical divisions. I authorize Childress Nursing Services to call in, at their discretion, any necessary consultants or activate emergency health care services. 

I have received, read/had explained to me, and understand the COVID-19 vaccine emergency use authorization (EUA) information sheet. I am the parent or legal guardian of the above child(s)/ward(s) and I give my permission for my child(s)/ward(s) to receive COVID-19 vaccine. I understand the benefits and risks of COVID-19 vaccine. I understand my child/ward's immunization information will go into a database other medical providers and school staff use.

I also understand that I am financially responsible for any co-pays and charges not covered by my insurance which are incurred as a result of this consent for treatment and care.

By signing this form, I give permission for a vaccination to be administered and a record of the vaccine be entered into a database for use to monitor control of the disease for me and/or my household. Further, I agree that the information provided is correct, and: (1) As the primary adult household member, I am responsible for making sure that me and my household members are present at the listed service address on the confirmed injection date and at least 10 minutes before the confirmed injection time by CNS (2) I (and my family, if applicable) have read the Covid-19 Vaccine EUA Fact Sheet provided (3) I (and my family, if applicable) understand the risks and benefits of getting the vaccine(s) and consent for me and my family to be vaccinated (4) Any questions I (and my family, if applicable) had about the vaccine(s) have been answered.

Click here for the Washington Dept. of Health’s answers to frequently asked questions about Covid-19 Vaccines: https://www.doh.wa.gov/Emergencies/COVID19/VaccineInformation/FrequentlyAskedQuestions 

Click here to review the Pfizer-BIONTECH COVID-19 Fact Sheet: https://www.fda.gov/media/144414/download

Click here to review the Moderna COVID-19 Fact Sheet: https://www.fda.gov/media/144638/download

Click here to review the Janssen COVID-19 Fact Sheet: https://www.fda.gov/media/146305/download

Acknowledgements:

• I (and my household members, if applicable) made the choice to get the COVID-19 vaccine on my own and freely. I know I have the option to refuse the vaccine. I ask that the vaccine be given to me, or to the person named above for whom I can make this request. I (and my household members, if applicable) was given the (Fact Sheet for Vaccine Recipients and Caregivers) for this vaccine. The fact sheet has information about side effects and adverse reactions. I read or had read to me the information provided about the COVID-19 vaccine.

• I (and my household members, if applicable) know the Food and Drug Administration (FDA) has authorized the emergency use of this vaccine. I know it is not a fully licensed FDA vaccine. I had the chance to ask questions that were answered to my satisfaction. I now know about the vaccine, alternatives, benefits, and risks, to the extent they are known and unknown at this time.

• I (and my household members, if applicable) know that we must stay in the vaccine area or an area told to me by my health care provider after I receive my immunization, so I am near my health care provider if I have any adverse reactions. If I have a history of certain allergic reaction(s), I must stay for 30 minutes. If I do not have a history of such an allergic reaction(s), I must stay for 15 minutes.

• I (and my household members, if applicable) know that if we have a severe allergic reaction, including difficulty breathing, swelling of my face and/or throat, a fast heartbeat, a bad rash all over my body or dizziness and weakness I should call 9-1-1 or go to the nearest hospital. I know that I can call my primary health care provider, if I have any side effects that bother me or do not go away.

• I (and my household members, if applicable) were asked to join the V-SAFE program. The program does health checks on the people who get the COVID-19 vaccine. I know I should report vaccine side effects to FDA/CDC Vaccine Adverse Event Reporting System (VAERS) at 1-800-822-7967 or https://vaers.hhs.gov/reportevent.html

• I (and my household members, if applicable) know that with all vaccines there is no promise I will become immune (not get the virus) or that I will not have side effects.

•If my (or my household members, if applicable) COVID-19 vaccine is a two-dose vaccine, I know that I must get twodoses and receive the same vaccine each time. I know I may choose to not get the second dose of the vaccine. But if I donot get the second dose, the chance that I will become immune may go down.

Authorization to Request Payment:

I (and my household members, if applicable) authorize the organization that is providing me (and my household members, if applicable) with vaccine to release information and request payment. I certify that the information given by me in applying for payment under private insurance, Medicare, Medicaid or the HRSA COVID-19 Program for Uninsured Patients, is correct. I authorize release of all records to act on this request. I request that payment of authorized benefits be made on my behalf.

Disclosure of Records:

I (and my household members, if applicable) understand the organization providing my vaccine may be required to or may voluntarily disclose my vaccine-related health information to my primary care physician, my insurance plan, health systems and hospitals, and state or federal registries or other public health authorities, for purposes of treatment, payment or health care operations. I also understand the organization providing my vaccine will use and disclose my health information per local, state and federal regulations according to HIPPA guidelines. If I am an employee of Childress Nursing Services, LLC, I understand that it will keep records of this vaccination for me in the E.H.R. system being used and may keep my vaccination records in Childress Nursing Services’ employee occupational health records, to the extent required or permitted by law.

We are honored to have the opportunity to service you and your family!

Childress Nursing Services (CNS)

Email: Vaccine@ChildressNursing.com  

Website: www.ChildressNursing.com