Compassionate Care Pharmacy COVID Vaccine Registration Form April 25 2021

COVID Vaccine Registration Form for 5/01/2021

Compassionate Care Pharmacy, Al Nahda, Worry Free Community, are partnering to make this event possible.
Compassionate Care Pharmacy is vaccinating based on State and Local Health Department direction.

LOCATION: AL Nahda Center

Address: 10555 SW Hwy #1250, Worth, IL 60482

PLEASE DO NOT CALL THE PHARMACY WITH REQUESTS FOR VACCINE APPOINTMENTS.
Name*

First NameLast Name
Maiden Name/Other Last Name
Date of Birth (must be 18 or older)*
Gender*

MaleFemaleOtherPrefer Not to Answer
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Email*
example@example.com
Phone*
Please enter a valid phone number.
VACCINE PRIORITIZATION

Please refer to Department of Public Health Vaccine Eligibility for how you must demonstrate your eligibility to receive the COVID vaccine and select the appropriate category that fits your description.
Which prioritization do you fall under?*

Age 75 or greaterQualify in Phase 165-74Low income senior housing resident or staff18+ (Others)
If you qualify for Phase 1, are you?

COVID-facing healthcare workerLong term care facility staff or residentFirst Responder (EMS, Police, Fire)Congregate Care setting staff or residentHome-based healthcare workerNon-COVID-facing healthcare workerNone of the Above
Some people qualify to receive the COVID-19 vaccine because of existing health conditions. Please refer to the CDC for further details about these qualifying conditions that place individuals at higher risk for COVID-19 complications. Please schedule an appointment with your provider if you have questions about your personal medical conditions and eligibility.
PRE-VACCINATION CHECKLIST

The following questions will help us determine if there is any reason you should not get the COVID-19 vaccine today. 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 healthcare provider to explain it.
Have you ever received a COVID Vaccine?*

YesNoDon't know
If yes, which product did you receive?

PfizerModernaOther
Primary Insurance
Member ID
Subscriber Name
Subscriber Date of Birth
Secondary Insurance
Secondary Member ID
Subscriber Name -- Secondary Insurance
Subscriber Date of Birth -- Date of Birth
Schedule Your Appointment
Saturday, May 01 2021 ~ 2:00pm- 6:00pm

ON THE DAY OF VACCINATION, please bring the following:
- Valid State ID or Driving License for Identification.
- Health Insurance Card.
Appointment
Consent:

All Information I have provided is correct and accurate to the best of my knowledge.

On the day of vaccination, I will bring a valid PictureID and health insurance card.
Should be Empty:

COVID Vaccine Registration Form for 5/01/2021

Schedule Your Appointment