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Vaccine Clinic Registration form
Kent Meridian High School Wednesday, September 18th, 2024 1pm-5pm
COVID VACCINES, ROUTINE CHILDHOOD VACCINES AVAILABLE FOR CHILDREN 0-18 YEARS. NO INSURANCE NECESSARY.
Patient's Name
First Name
Last Name
Birth Date
Please select a month
January
February
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September
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December
Month
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Day
Please select a year
2024
2023
2022
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Year
Sex
Male
Female
Gender Identity
Male
Female
Non-Binary
Other
Parent/Caregiver's Name
Relationship to the patient
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Email Address
Phone Number
Racial Identity
White
Black
Asian
Native Hawaiian or Pacific Islander
American Indian/Alaska Native
Other
Ethnicity
Hispanic/Latino
Not Hispanic/Latino
Insurance Provider *INSURANCE IS NOT REQUIRED*
Premera
Regence BCBS
Aetna
Cigna
Kaiser
First Choice Health Network
Molina Apple Health
ProviderOne or Other Apple Health Plan
Other
Insurance ID Number
Insurance Group Number
Insurance Subscriber
Subscriber Date of Birth
-
Month
-
Day
Year
Date
Subscriber Relationship to Patient
Picture of Insurance Card
Browse Files
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Cancel
of
I give consent for my child to receive:
All required and recommended childhood vaccines
COVID Vaccine
Annual Flu Vaccine
Only specific vaccines (please specify below)
Other Information
Signature
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