Temple Beth El (Dec 03)

Patient Information and Consent Form
You are currently registering for an upcoming vaccine clinic at Temple Beth El from 10 AM to 2 PM on December 3, 2025. Please plan to arrive any time during this time block, first come first served. This form will take 2-5 minutes to complete.
Patient Information
First Name*
Last Name*
Street*
City*
State*
Zip Code*
5 digits
Mobile Phone*
Please provide your mobile phone number, or best number to reach you.
Email*
example@example.com
Today

MonthDayYear
Date of Birth*

MonthDayYear
Current Age
Gender*
Ethnicity
Insurance Information
Please provide a photo of the front of your insurance card

Cancelof
I know my Medicare Number.*

YesNo
Medicare HIC*
Please provide your Medicare Number so we can look up your Medicare coverage. Your Medicare Number is an 11 digit alpha-numeric code below your name on your Medicare card.
Please provide the last four digits of your Social Security number so we can look up your Medicare coverage.*
Screening Questionnaire
Are you sick or do you currently have a fever?*

YesNoI don't know
Do you have a known allergy to any components of the vaccine, for example, eggs, polyethylene glycol (PEG), polysorbate, a previous injection of any kind?*

YesNoI don't know
Do you have a history of immune-mediated syndromes such as thrombosis, thrombocytopenia, or heparin-induced thrombocytopenia?*

YesNoI don't know
Do you have a history of myocarditis or pericarditis?*

YesNoI don't know
Do you have a weakened immune system (i.e., HIV infection, cancer, organ transplant, DiGeorge Syndrome or Wiskott-Aldrich Syndrome) or take immunosuppressive drugs/therapies, (high dose corticosteroids, CAR-T-cell therapy, hematopoietic cell transplant HCT)?*

YesNoI don't know
Consent for Vaccination
I hereby give my consent to receive vaccines for (check all that apply):*

COVIDInfluenza
I understand the potential risks and benefits of the vaccine(s) I have given my consent to receive above as summarized at the CDC website: https://www.cdc.gov/vaccines/hcp/current-vis/index.html*

Yes
I understand that as required by state law, all immunizations will be reported to the Department of Public Health Massachusetts Immunization Information System (MIIS). I can access the MIIS Fact Sheet for Parents and Patients at www.mass.gov/dph/miis*

Yes
I give permission for Union Pharmacy to bill my healthcare insurance company for the costs of administering the vaccine.*

Yes
I understand that I am ultimately responsible for any charges that are not covered by my insurance plan.*

Yes
I have reviewed this entire Patient Information and Consent Form and hereby certify it is true and correct to the best of my knowledge.*

Yes
Patient Signature*

Clear
Name of Parent/Guardian*

First NameLast Name
Parent/Guardian Signature*

Clear
Please verify that you are human*
Should be Empty:

Patient Information and Consent Form

Patient Information

Insurance Information

Screening Questionnaire

Consent for Vaccination