Vaccine Clinic Registration form

Patient's Name

First NameLast Name

Birth Date

MonthDayYear

Sex

Gender Identity

Parent/Caregiver's Name

Relationship to the patient

Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Email Address

Phone Number

Racial Identity

Ethnicity

Insurance Provider *INSURANCE IS NOT REQUIRED*

Insurance ID Number

Insurance Group Number

Insurance Subscriber

Subscriber Date of Birth

Date

Subscriber Relationship to Patient

Other Information

Picture of Insurance Card

I would like my child to receive the following vaccines:

I would like my child to receive their vaccine(s) during the school day without a parent present.

I would like to be present for my child's vaccine(s) and I will bring them to receive their vaccines between 2:30pm and 5pm.

Signature

COVID AND FLU VACCINES AVAILABLE FOR CHILDREN 0-18 YEARS.