Clinic (E) Registration COVID Booster Vaccine Saturday Event 02.12.2022

Registration for UITCT COVID-19 Vaccination Event

February 12,2022
This form will be used for registration and pre-screening for vaccination eligibility at UITCT. UITCT is following IHS, CDC, and state guidelines for the administration of the vaccine. It is important that you double-check the contact information in this section so that we will be able to reach you.

If you qualify for the COVID booster and did not receive your previous doses at UITCT, you must bring proof of your first 2 vaccinations with you to your visit.
Name *

First Name Last Name
Date of Birth *

Month Day Year
Date
Address *

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
County of Residence *
Cellphone Number *
Please enter a valid phone number.
Email *
example@example.com
Gender *

Female Male Decline to Specify Other
Ethnicity *

Hispanic or Latino Not Hispanic or Latino Unknown / not reported
Race *

American Indian or Alaska Native Asian Black or African American Native Hawaiian or Pacific Islander White Unknown / not reported
Tribe of Membership
Vaccine received? *

Moderna Pfizer
Date of first dose. *

Month Day Year
Date
Facility of first dose. *
Date of second dose. *

Month Day Year
Date
Facility of second dose. *
Have you been seen for a medical visit at the UITCT clinic within the past 3 years? *

Yes No
Would you like to receive a flu shot at this event?

Yes No
Are you a member of a state or federally recognized tribe? *

Yes No
Have you been exposed or tested positive for COVID-19 within the past 14 days? *

Yes No
Are you pregnant? *

Yes No
You are currently not eligible to receive the COVID-19 Vaccine from UITCT at our Mass Vaccination Event.

Stay updated on your Vaccine Booster Eligabiity at UITCT.org.

Call our office if you have further questions.
YOU ARE ELIGIBLE TO REGISTER TO RECEIVE THE COVID-19 VACCINE FROM UITCT.

Please choose your appointment time. You will not receive a phone call from UITCT to confirm your time, once submitted your time is reserved. You MUST bring a photo ID, birth certificate, or passport to receive a vaccination. Please arrive as close to your appointment time as possible, arriving early or late could cause delays in receiving your vaccination.
Appointment
Should be Empty:

Registration for UITCT COVID-19 Vaccination Event