COVID Vaccine Consent Form

Updated COVID Vaccine Appointment Form

* Please fill out the required details below
Section I. Personal Information
Full Name:*

First NameMlLast Name
Date of Birth:*

MonthDayYear
Age:*
Phone Number:*
Email*
example@example.com
Gender:*

MaleFemale
Address:*

Street Address Line 2
Section II. Appointment Scheduler
Choose your vaccine *

Updated Moderna (12+ yrs)Updated Pfizer (12+ yrs) (COMIRNATY)Updated Moderna (3 yrs - 11 yrs)Updated Pfizer (5 yrs - 11yrs)
Do you want to get FLU Vaccine*

YesNo
**Vaccine supply is limited. Please keep your appointment or E-mail us if you need to cancel or change it. Additionally, due to vaccine requirements, we may call you to see if you can come earlier or later. If you miss an appointment, no doses will be held to guarantee your dose.**
Please pick a day and time for your vaccination*
Section III. Insurance Details And Signatures

I understand that the updated Covid vaccine is not free and I have been informed that the services provided may not be covered by my insurance plan. I elect to proceed with service with the understanding that I may be personally responsible to pay for the service being rendered to me.
Please choose one of the options below about your insurance :*

I am insured and can provide proof of InsuranceI do not have any insurance, including but not limited to Medicare, Medicaid or any other private or government-funded health benefit plan
If uninsured, you may be eligible for a free Covid-19 vaccination. Please visit WWW.COVIDAccess.com OR Call (800) 635-8611 to get a voucher for free Covid-19 vaccine.
Please upload pictures of front & back of your insurance card for billing purposes. Medicare recipients please attach your Medicare (Red, Blue and white) card. If uninsured and got the voucher please upload here.

Browse Files

Cancelof
Please upload your id

I have attached my id below
Please Upload picture of your Driver's license/Any State Issued Photo ID.

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Cancelof
Please check the box below*

I authorize the pharmacy to bill my insurance on my behalf for the immunization
By clicking the "Submit" button below, you certify that the above information is correct and accurate to the best of your knowledge. All information is confidential and is accessed only via a secure, encrypted interface.
Signature of the Person to Receive Vaccine (or Signature of Parent/Guardian if Patient is < 18 yo)*

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Updated COVID Vaccine Appointment Form