JCC March 2026

Patient Information and Consent Form
You are currently registering for an upcoming COVID vaccine clinic to be held at JCC on:
- Mar 23 9AM - 11AM and
- Mar 25 12PM - 2PM
You may arrive any time during these time blocks, first come first served. This form will take 2-5 minutes to complete.
Monday March 23, 9 AM - 11 AMWednesday March 25, Noon - 2 PM
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
I will type the information from my insurance cardI will provide a photo of the front of my card
Insurance Co.* Member ID* Group Number Rx PCN* Rx Bin* Rx Group*
Photo of Front of Insurance Card*

Cancelof
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
YesNoI don't know
YesNoI don't know
YesNoI don't know
YesNoI don't know
YesNoI don't know
Consent for Vaccination
COVID
Yes
Yes
Yes
Yes
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