Vaccine Clinic Registration form

Vaccine Clinic Registration form

Federal Way High School Monday, September 30th, 2024 3pm-6pm
COVID VACCINES, ROUTINE CHILDHOOD VACCINES AVAILABLE FOR CHILDREN 0-18 YEARS. NO INSURANCE NECESSARY.
Patient's Name

First NameLast Name
Birth Date

MonthDayYear
MaleFemale
MaleFemaleNon-BinaryOther
Parent/Caregiver's Name
Relationship to the patient
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Email Address
Phone Number
WhiteBlackAsianNative Hawaiian or Pacific IslanderAmerican Indian/Alaska NativeOther
Hispanic/LatinoNot Hispanic/Latino
PremeraRegence BCBSAetnaCignaKaiserFirst Choice Health NetworkMolina Apple HealthProviderOne or Other Apple Health PlanOther
Insurance ID Number
Insurance Group Number
Insurance Subscriber
Subscriber Date of Birth

MonthDayYear
Date
Subscriber Relationship to Patient
Picture of Insurance Card

Cancelof
All required and recommended childhood vaccinesCOVID VaccineAnnual Flu VaccineOnly specific vaccines (please specify below)
Other Information
Signature

Powered by Jotform SignClear
Should be Empty:

COVID VACCINES, ROUTINE CHILDHOOD VACCINES AVAILABLE FOR CHILDREN 0-18 YEARS. NO INSURANCE NECESSARY.