Home-Visit Vaccine Sign-Up
Please fill out this form in its entirety and to the best of your ability. A member of our team will reach-out once this form is completed to review availability. Note: All insurance information collected is solely for claim-processing purposes and will only be used to bill your insurance for the vaccines. If you have any questions about this form, please contact our team by phone at 717-626-2222.
Name of PATIENT RECEIVING VACCINE
*
First Name
Last Name
Email:
*
example@example.com
Date of Birth PATIENT RECEIVING VACCINE
*
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Address where you'd like to RECEIVE VACCINE
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Contact Phone Number:
*
Please enter a valid phone number.
Format: (000) 000-0000.
Which Vaccine are you scheduling an appointment for?
*
COVID-19
FLU
RSV
SHINGLES
PNEUMONIA
TETANUS
Other
Insurance information: Please input the numbers/letters from your Prescription Insurance card, or bridge voucher, or if applicable, Medicare B Card, below. IF you have Medicare Part B through AETNA HMO, UNITED HEALTHCARE HMO (i.e. Verizon employees), or any other Part B, please put that card info below. You are looking at your prescription card if it has the letters RX on it otherwise, you are likely looking at your medical card. If your card does not have one of the below, please leave that field blank. If you do not have insurance, put in the last 4 of your SSN. After filling it out, hit "Next." Not providing this information now could delay your registration on-site.
Request
Should be Empty: