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Allen County Public Library's Respiratory Vaccination Clinic
Register to participate in the Fall Immunization Clinic with Super Shot.
Please select which library location/clinic you intend to attend:
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Please Select
New Haven on Monday September 21st
Main on Tuesday September 22nd
Pontiac on Wednesday September 23rd
Woodburn on Thursday October 1st
Georgetown on Saturday October 3rd
Waynedale on Saturday October 3rd
Grabill on Thursday October 15th
Monroeville on Saturday October 17th
Shawnee on Tuesday October 20th
Little Turtle on Wednesday October 21st
Hassen Cassel on Thursday October 22nd
Are you completing this form for a child or an adult?
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Child
Adult
Child's Name
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First Name
Last Name
Patient's Name
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First Name
Last Name
Child's Date of Birth
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Month
/
Day
Year
Date
Patient's Date of Birth
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/
Month
/
Day
Year
Date
Child's Gender
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Male
Female
Patient's Gender
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Male
Female
Parent/Guardian's Name
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First Name
Last Name
Patient's Home Address
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Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Mobile Phone Number
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Please enter a valid phone number.
Format: (000) 000-0000.
Email
*
example@example.com
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Required Health Insurance Information
Select insurance type:
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Private Insurance (ex: CIGNA, PHP, BCBS, Signature Care)
TRICARE
Medicaid (ex: Healthy Indiana Plan, Hoosier Care Connect, Hoosier Healthwise, CareSource)
Medicare or Medicare Replacement/Advantage Plan (ex: Humana Gold, UnitedHealth Care)
No Insurance
I certify that the patient is not covered by any health insurance
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Yes
No
Insurance Company
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Member ID
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DoD ID Number
Member ID
Group Number
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Policy Holder's Name
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First Name
Last Name
Policy Holder's Date of Birth
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Month
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Day
Year
Date
Social Security Number
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The service member's SSN is required for processing
Social Security Number
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Medicare requires the Patient's SSN for reimbursement purposes
Policy Holder's Relationship to Patient
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Upload Insurance Card Image (Front)
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Browse Files
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Choose a file
Cancel
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Upload Insurance Card Image (Back)
*
Browse Files
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of
Do you have an additional Medicare Card (Red, White, Blue or Advantage Plan Card?)
Medicare requires us to capture images of both Advantage Plan cards, and traditional Medicare cards cards, if available, for billing purposes. If you have any questions, please call Super Shot at (260)424-7468 and ask for Janet or email Janet.Paunwar@supershot.org. Thank you!
Upload Additional Insurance Card Image (Front)
Browse Files
Drag and drop files here
Choose a file
Cancel
of
Upload Additional Insurance Card Image (Back)
Browse Files
Drag and drop files here
Choose a file
Cancel
of
Upload Insurance Card Image (Front)
Browse Files
Drag and drop files here
Choose a file
Cancel
of
Upload Insurance Card Image (Back)
Browse Files
Drag and drop files here
Choose a file
Cancel
of
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Demographic Information
Number of people living in the household
Annual Household Income (Current)
Below $11,800
$11,801 - $24,300
$24,301 - $36,450
$36,451 - $48,600
$48,601 - $60,750
$60,751 - $72,900
Over $72,901
Race
Please Select
American Indian/Alaskan Native
Asian
Black/African American
Burmese
Hispanic/Latino
Middle Eastern/North African
Native Hawaiian/Pacific Islander
White
Declined
Ethnicity
Please Select
Hispanic/Latino
Not Hispanic/Latino
Declined
Language spoken at home
Please Select
English
Spanish
Burmese
Other
Do you have a disability?
Yes
No
Prefer not to say
What type of disability do you have?
ADHD
Anxiety or Depression
Autism or ASD
Blindness/Vision Loss
Hearing Loss/Deafness
Learning or intellectual impairment
Mental Health diagnosis
Neurological disorder (epilepsy, MS, muscular dystrophy, etc)
Physical impairment in one or more limb
Speech or language difficulties
None of these apply
Other
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Health Screener
Please complete all health screening questions for the person getting the vaccines.
Patient's Primary Care Provider
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Is the person to be vaccinated allergic to any medications, food, vaccine ingredients or latex (ex: gentamicin, alginine, gelatin, MSG)
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Yes
No
Please list all applicable allergies:
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Has the person to be vaccinated ever had a serious reaction to a vaccine in the past?
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Yes
No
Describe the serious reaction:
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Does the person to be vaccinated have a long-term health problem with heart disease, lung disease (including asthma), kidney disease, neurologic disease, liver disease, or metabolic disease (e.g., diabetes)?
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Yes
No
Does the person to be vaccinated have a) an open channel between the cerebrospinal fluid (CSF) and the mouth, throat, nose or ear or any other cranial CSF leak, or b) a cochlear implant, or c) an immunocompromising condition due to any cause (e.g., medication, congenital or acquired immunodeficiency, HIV infection, or a missing or non-functioning spleen [e.g., caused by sickle cell disease])?
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Yes
No
Is the person to be vaccinated currently taking influenza antiviral medications, or have they taken any within the past 3 weeks?
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Yes
No
Don't know
Is the person to be vaccinated a child or teen age 6 months through 17 years and receiving aspirin- or salicylate-containing medicine?
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Yes
No
Don't know
Has the person to be vaccinated ever been diagnosed with a heart condition (myocarditis or pericarditis) or have you had Multisystem Inflammatory Syndrome (MIS-A or MIS-C) after an infection with the virus that causes COVID-19?
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Yes
No
Is the person to be vaccinated pregnant or is there a chance they could become pregnant within a month of being vaccinated?
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Yes
No
Not Applicable
Does the person to be vaccinated have a history of Guillain-Barre syndrome (GBS)?
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Yes
No
Does the person to be vaccinated live with or expect to have close contact with a person whose immune system is severely compromised and who must be in protective isolation (e.g., an isolation room of a bone marrow transplant unit)?
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Yes
No
Don't know
Has the person to be vaccinated received any other vaccinations in the past 4 weeks?
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Yes
No
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Consent
I would like Super Shot to administer the following vaccines:
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Flu Shot - Injectable Influenza Vaccine (recommended for age 6 month+)
Flu Mist - Live Attenuated Intranasal Influenza Vaccine (recommended for age 2 through 49 years)
Updated COVID
Pneumococcal (recommended for age 50+ or those younger with risk factors)
If I am 65 years old or order, I would like the 'enhanced' version of the flu and/or COVID vaccines as is recommended for my age.
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Yes
No, please give me the vaccine recommended for 19-64 year olds.
Not applicable
U.S. Centers for Disease Control and Prevention (CDC) now recommends COVID-19 vaccines for adults and children at risk for severe disease. The COVID-19 vaccine is indicated for those less than 65 years old as follows: (1) those that have consulted with a medical professional and determined that the vaccination is appropriate and/or (2) those with any risk factors at https://www.cdc.gov/covid/risk-factors/index.htm
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I have read the following recommendation and should receive my COVID vaccine at this time
U.S. Center for Disease Control and Prevention (CDC) recommends the 21-valent pneumococcal vaccine (PCV21, Capvaxive) for all adults age 50 and older. Adults younger than 50 may also need this vaccine if they have certain health conditions that increase their risk. You can learn more about those risk factors on the CDC website: https://www.cdc.gov/pneumococcal/causes/index.html#cdc_causes_risk-risk-factors
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I have read the following recommendation and should receive my Pneumococcal vaccine at this time.
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Communication Preference:
It is OK to call me
It is OK to text me
All information I have provided on the consent for vaccination is true and correct. I have legal authority to consent for all vaccination services rendered. I am aware of the HIPAA Notice of Privacy Policy available at supershot.org. I am aware and understand the CDC Vaccine Information Statements for the vaccines the patient will receive today available at https://www.cdc.gov/vaccines/hcp/vis/index.html I give permission to Super Shot to give the patient vaccines indicated in my absence and use all information provided to communicate with other healthcare providers or other entities as needed, for data entry, billing, and storage according to Indiana Department of Health policies. By signing below I agree to the payment option indicated for services performed. I understand that a claim will be filed to my insurance company for vaccination services rendered.
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I attest
Signature
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Parent/Guardian's Name
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Today's Date
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Month
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Day
Year
Date
Register
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