Name (of the patient receiving the shot)
*
First Name
Last Name
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Date of Birth
*
/
Month
/
Day
Year
Gender
*
Please Select
Male
Female
Prefer not to answer
Phone Number
*
Please enter a valid phone number.
Email
*
example@example.com
Are you a staff member?
*
Yes
No
I authorize VaxOn to text me or leave a detailed message regarding my visit today on the voicemail of the telephone number I have provided.
*
Yes
No
If filling for a child, What's the Name of the parent completing the form:
*
if you are filling it for yourself put N/A
Which vaccine would you like to get?
*
Flu Vaccine
Adult COVID-19 (25/26)
Pediatric COVID-19 (25/26)
Appointment
*
Please answer all the following Questions:
*
Yes
No
1- Do you have an allergy to medications, foods, or any vaccines (eggs, gelatin, thimerosal, neomycin, gentamicin, latex, aluminum, preservatives, baker's yeast, etc.)?
2- Have you ever had a serious reaction or fainted after receiving any vaccination?
3- Have you ever had a seizure, brain disorder, or Guillain-Barre Syndrome?
4- Do you have any chronic health condition such as Cancer, Chronic Kidney Disease, Immunocompromised, Chronic Lung Disease, Obesity, Sickle Cell Disease, Diabetes, Heart Disease, Other?
Do you have health insurance, Medicare, Medicaid or any commercial or government-funded health benefit plan?
*
Yes
No
Select insurance company, or Medicare or Medicaid plan
*
Please Select
Aetna
Blue Cross Blue Shield
Bright Health
Cigna
Medicaid
Medicare
Tricare
United Health Care
Other
Please upload your insurance Card
*
Browse Files
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Provide an image of your insurance card to help avoid errors in billing your insurance company.
Cancel
of
Signature
*
Provider
Eslam Said
Mariam Fadaly
Lot#
For Self Paying Patients ONLY
*
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Flu Vaccine
Please enter a short description.
$
45.00
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