Where would you like to get your COVID-19 Vaccination?
*
Please Select
EUTAW HOUSING AUTHORITY
SELMA UNIVERSITY
AREA FOR AGING, HAYNEVILLE
AREA FOR AGING, MONTGOMERY
TRINITY FIRE DEPT
STEELECASE/TURNER
AL COALITION of IMMIGRANT JUSTICE, ALBERTVILLE
AL COALITION of IMMIGRANT JUSTICE, CULLMAN
AL COALITION of IMMIGRANT JUSTICE, MOBILE
AL COALITION of IMMIGRANT JUSTICE, TUSCALOOSA
FIRST BAPTIST CHURCH, HUNTSVILLE
LULAC Council, HUNTSVILLE
METRO TREATMENT CENTER
NEW FUTURE FAMILY LODGE
WELL STONE CONNECT TO HEALTH
WENDY HILL SUBDIVISION
AMSI
Where would you like to get your COVID-19 Vaccination?
*
Please Select
CITY OF JACKSONVILLE
L & L LUMBER
DEPT. OF HUMAN RESOURCES - HUNTSVILLE
PICKENS COUNTY
FOREST COMMUNITY CENTER
BETHEL BAPTIST CHURCH
CORNERSTONE GOSPEL BAPTIST CHURCH
EAST BIRMINGHAM COGIC
ALL NATIONS CHURCH
NEW LIFE WORSHIP CENTER
ANDREW CHAPEL AME ZION CHURCH
LULAC Council, DRAKE AVE, HUNTSVILLE
LULAC Council, BOAZ
LULAC Council, RICHARD SHOWERS CENTER
SALEM CHAPEL AME CHURCH
SELMA UNIVERSITY
HOGAN YMCA
AAMU LIFE CENTER
METRO TREATMENT CENTER
SALVATION ARMY
FIRST STOP HOMELESS
THE LEGACY CENTER
FIRST BAPTIST CHURCH HUNTSVILLE
PLACE APARTMENTS
SIDNEY CHAPEL AME ZION CHURCH
WELL STONE CONNECT TO HEALTH
ST. LUKES CHRISTIAN CHURCH
AMSI TESTING
AL COALITION of IMMIGRANT JUSTICE, ALBERTVILLE
Appointment Time
Please Select
7:00 AM
7:15 AM
7:30 AM
7:45 AM
8:00 AM
8:15 AM
8:30 AM
8:45 AM
9:00 AM
9:15 AM
9:30 AM
9:45 AM
10:00 AM
10:15 AM
10:30 AM
10:45 AM
11:00 AM
11:15 AM
11:30 AM
11:45 AM
12:00 PM
12:15 PM
12:30 PM
12:45 PM
1:00 PM
1:15 PM
1:30 PM
1:45 PM
2:00 PM
2:15 PM
2:30 PM
2:45 PM
3:00 PM
3:15 PM
3:30 PM
3:45 PM
4:00 PM
4:15 PM
4:30 PM
4:45 PM
5:00 PM
5:15 PM
5:30 PM
5:45 PM
6:00 PM
6:15 PM
6:30 PM
6:45 PM
7:00 PM
7:15 PM
7:30 PM
7:45 PM
Appointment Date
*
-
Month
-
Day
Year
Day Date
Name
*
First Name
Last Name
Guardian/Parent: (Print) If Applicable
Relationship to Minor
Date of Birth
*
/
Month
/
Day
Year
Date
Last 4 Digits of Social Security #
Age
Sex
*
Please Select
Male
Female
Ethnicity
*
Please Select
African American
Caucasian
Hispanic
Asian American/Pacific Islander
Phone #
*
Email Address
example@example.com
Address
*
City
*
County
*
State
*
Zip
*
Insurance
*
Please Select
Patient’s Own Insurance
Someone Else’s Insurance
No Insurance
Social Security #: *REQUIRED IF NO INSURANCE
Insurance Provider
*
Please Select
BC/BS
Medicaid
Medicare
Humana
United Healthcare
AETNA
TRICARE
NONE
Other
Policy Number
Group Number
Other Insurance Provider
Effective Date of Policy
/
Month
/
Day
Year
Date
Policy Holder's Name
Policy Holder's DOB
Relationship to Policy Holder
Please Select
Self
Parent
Legal Guardian
Other
Other
Policy Holder's Address
ACKNOWLEDGEMENT, AUTHORIZATION, VACCINATION and HEALTH RELATED INFORMATION
* ALL QUESTIONS & STATEMENTS REQUIRE ANSWERS *
Has the patient tested positive for Coronavirus (COVID-19) in the past 90 days?
*
Please Select
Yes
No
Has the patient received monoclonal antibody therapy within the past 90 days?
*
Please Select
Yes
No
Has the patient had a steroid injection within the past 2 weeks?
*
Please Select
Yes
No
Has the patient ever received a COVID-19 vaccination?
*
Please Select
Yes
No
Manufacturer
If yes, Date Given
-
Month
-
Day
Year
Date
Does the patient have any long term health problems?
*
Please Select
Yes
No
Please list long term health issues here
Has the patient had a life threatening reaction to any injectable medication, a COVID-19 vaccine or to a vaccine component (example: eggs, thimeroal, gelatin or bovina protein)?
*
Please Select
Yes
No
Has the patient had a seizure or any other brain or other nervous system problems (i.e.Guillian-Bartt syndrome after receiving a vaccine)?
*
Please Select
Yes
No
For Women: Are you pregnant or considering getting pregnant in the next 3 months or are you currently nursing?
*
Please Select
Yes
No
N/A
I have read and understand the HIPAA/Privacy Policy for AMERICAN MEDICAL SCREENING, INC. which can be found in its entirety at americanmedicalscreening.org.
I authorize to have any of my test results delivered to me by email, phone or text .
I authorize AMERICAN MEDICAL SCREENING, INC. to release/share medical information and/or test results with my primary care physician (when provided), ADPH and/or the CDC.
Patient/Guardian Signature
Clear
Date
/
Month
/
Day
Year
Date
Submit
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