Fig Tree Pediatrics - Flu and COVID Vaccine Registration
Schedule your family flu and COVID vaccines at Fig Tree Pediatrics! Members and non members are welcome. Most commercial insurance is in network for vaccines only. Please complete 1 registration per person.
Name of Patient
*
First Name
Last Name
Date of Birth
*
-
Month
-
Day
Year
Date
Gender
*
Male
Female
Email
*
example@example.com
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Please choose a vaccine appointment (please choose one for each member of your family)
*
Which vaccines are you planning to receive?
*
Flu
COVID
Will you be using insurance for your vaccine?
*
Yes
No
What is your insurance carrier?
*
What is your insurance member number?
*
What is your insurance group number?
*
Who is the primary insured on the account?
*
What is the date of birth of the primary insured?
*
What is the patient's relationship to primary insured?
*
Self
Dependent
Spouse
Has the patient received this vaccine before (flu, COVID or both depending on which you are planning on)?
*
Yes
No
Did the patient have any life threatening reaction in the past when they received this vaccine?
*
Yes
No
Does the patient have Guillain-Barre syndrome?
*
Yes
No
Does the patient have a long-term serious health problem? (like heart, lung, kidney problems, etc.)
*
Yes
No
Signature
*
Date Signed
*
-
Month
-
Day
Year
Date
Name of guardian who is signing on behalf of the patient (self if age > 18, or name of parent if < 18)
*
First Name
Last Name
Relationship to Minor Patient
*
Self
Parent
Guardian
Submit
Submit
Should be Empty: