Flu/Covid Vaccine Clinic Thursday, October 10, 2024 3:30pm-6pm
Anderson Middle School Cafeteria
How many patients/family members are registering?
*
1
2
3
4
5
6
Please select 1 Covid vaccine option per patient only (Moderna or Pfizer) & Add Flu vaccine if desired
Patient 1 Information
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Full Name
Date of Birth
Vaccine(s) for Patient 1. Please select the vaccine(s) to be administered.
*
Moderna Covid Vaccine or
Pfizer Covid Vaccine
Add Flu Vaccine
Patient 2 Information
Legal Full Name
Date of Birth
Vaccine(s) for Patient 2. Please select the vaccine(s) to be administered.
Moderna Covid Vaccine or
Pfizer Covid Vaccine
Add Flu Vaccine
Patient 3 Information
First
Date of Birth
Vaccine(s) for Patient 3. Please select the vaccine(s) to be administered.
Moderna Covid Vaccine or
Pfizer Covid Vaccine
Add Flu Vaccine
Patient 4 Information
Legal Full Name
Date of Birth
Vaccine(s) for Patient 4. Please select the vaccine(s) to be administered
Moderna Covid Vaccine or
Pfizer Covid Vaccine
Add Flu Vaccine
Patient 5 Information
Legal Full Name
Date of Birth
Vaccine(s) for Patient 5. Please select the vaccine(s) to be administered
Moderna Covid Vaccine or
Pfizer Covid Vaccine
Add Flu Vaccine
Patient 6 Information
Legal Full Name
Date of Birth
Vaccine(s) for Patient 6. Please select the vaccine(s) to be administered
Moderna Covid Vaccine or
Pfizer Covid Vaccine
Add Flu Vaccine
Home Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Parent/Guardian Name
*
First Name
Last Name
Parent/Guardian Phone Number
*
Parent/Guardian E-mail
*
example@example.com
Upload Front Image of Parent Photo ID/Driver's License
*
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Primary Insurance Type
*
BCBS/BCN
Medicaid
HAP
UHC
Other/Uninsured/Self-Pay
Insurance Policy Information
*
Subscriber/Member ID #
Group Number
Insurance Subscriber Name & Date of Birth
*
Full Name
Date of Birth
Upload Front Image of Insurance Card
*
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Choose a file
Cancel
of
Upload Back Image of Insurance Card
*
Browse Files
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Choose a file
Cancel
of
Select one appointment time that will include all registered patients/family members listed
*
Submit Form
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