Tarrant County Empowering Seniors Expo 2026

Vaccine Clinic Registration and Consent

Get your vaccines at the expo, free of charge to you if you have insurance. Complete this quick form ahead of time so we can have everything ready when you arrive. Walk-ups are welcome too, but signing up early helps us move faster on-site. Sign up online until 24 hours before the event.
Attendee Name

FirstNameLastName
Attendee Date of Birth

MonthDayYear
DateOfBirth
Who is receiving the vaccine? Choose one to see available appointment times.
Appointment Scheduling

Please select a date and time for your vaccination appointment. If you will be receiving multiple vaccines, they will be administered at the same appointment time.
Assisted Living Appointment: Please choose an appointment time
Memory Care Appointment: Choose any appointment time. We will vaccinate residents during the scheduled clinic window.
Attendees Appointment: Please choose an appointment time
Team Member Appointment: Please choose an appointment time
Click "Next" to Choose Vaccines

Once you have filled out your Name, Date of Birth, and selected an appointment time, go to the next page to choose what vaccines the patient would like to receive.

Attendee Age Calculated (In Years:)
Vaccine Selection

Only vaccines appropriate for the resident's age will appear after you make your selection.
Which vaccines would you like to receive? (Select all that apply)
Date of Appointment:

MonthDayYear
Date
Flu vaccine for this age group: Ages 1 to 64
Flu vaccine for this age group: Ages 65 and Older
COVID-19 vaccine option for this age group: Ages 1 to 4
Select COVID-19 vaccine option for this age group: Ages 5 to 11
Select COVID-19 vaccine option for this age group: Ages 12 to 64
Select COVID-19 vaccine option for this age group: Ages 65 and up
Other optional vaccines (if needed)
About Other Optional Vaccines
- Pneumonia (Pneumococcal): Protects against 21 types of pneumonia. Recommended for adults aged 50+, or 18-49 with certain medical conditions. May depend on prior vaccination history.
- RSV (Respiratory Syncytial Virus): Protects against Respiratory Syncytial Virus. Recommended for Adults aged 60+, or 18-59 with certain chronic conditions. Typically a single dose.
- Tdap: Protects against tetanus, diphtheria, and whooping cough. Most adults receive a booster every 10 years.
Some people can get this vaccine earlier because of certain health problems. Do you have a health problem that lets you get this vaccine? If yes, please tell us which one.
Ineligible for Vaccine based on Age

This vaccine is only for people above a certain age. You are not in that age group, so we cannot book this vaccine for you. Please choose another option.

Please email the clinic if you have more questions, and thank you for understanding!
Pediatric COVID-19 Vaccine Attestation:

I acknowledge that the CDC recommends COVID-19 vaccination for individuals ages 6 months–17 years under Individual/Shared Clinical Decision-Making (SCDM) guidance. After reviewing this recommendation and discussing my child’s personal health circumstances with Tarrytown Pharmacy, I have chosen to proceed with vaccination. I understand that this decision reflects both my preference as parent/guardian and consideration of the potential risks and benefits. I hereby authorize Tarrytown Pharmacy's pharmacists, as a licensed healthcare provider, to order and administer the COVID-19 vaccine for my child.
COVID-19 Vaccine Eligibility: (Please select one)
Underlying conditions that put patients at high risk for severe COVID-19 outcomes: Please select one. **The first option can be selected if the patient does not have a condition listed and still wants to receive the COVID-19 vaccine.
Please select the date of your last vaccine dose (if applicable)

MonthDayYear
Date
Attendee Demographic Information Continued
Attendee Gender (as associated with your insurance):
Email for vaccine communication:
example@example.com - *This can be the resident’s or the legal representative’s email.
Cell Phone Number: (Please double check for accuracy)
Please enter a valid phone number. Only enter the numbers no ( ) or dashes. *This can be the resident’s or their legal representative’s number.Format: 0000000000.
Resident Primary Phone Number: (Please double check for accuracy)
Please enter a valid phone number. Only enter the numbers no ( ) or dashesFormat: 0000000000.
Resident Room Number:
Attendee Address

AddressOne

AddressTwo

CityStateCode

Zip
Health Insurance Coverage
Does the attendee/patient have health insurance?
Community Team Member Insurance: Because you answered YES to the question above, please select which type of insurance you have: (Select All That Apply)
Because you answered YES to the question above, please select which type of insurance you have: (Select All That Apply)
Social Security Number (used only if needed to verify Medicare or insurance coverage)
Occasionally Medicare or insurance information is entered incorrectly. Providing a Social Security Number allows us to locate the correct insurance record so your vaccine can be billed properly. This information is stored securely in accordance with HIPAA and used only for insurance verification.
Docstation BIn
Medicare Part B Insurance Information

Medicare coverage for Medical and Office Visits
Medicare Part B ID# (red, white, and blue card for patients over 65)
Please do NOT include any dashes or spaces. *if you are not over 65 or do not have part B, enter "n/a".
RxBin
RxBin
RxPcn
RxPcn
MemberID
MemberID
MedicareBeneficiaryIdentifier
MedicareBeneficiaryIdentifier
Medical Insurance Information

Coverage for Medical and Office Visits
Insurance Company Name:

Other
Member/Subscriber ID:
Please include LETTERS AND NUMBERS in your Member ID
RxBin2
RxBin2
RxPcn2
RxPcn2
MemberID2
MemberID2
Medicaid Information
MEDICAID Number:
Upload a photo of the resident's Medicare Part B or Advantage Insurance Card:

Cancelof
Attendee Medical History

Enter Attendee Medical History:

Rows	Yes	No	Don't Know
Have you ever experienced a serious reaction after getting a vaccine?
Have you ever felt dizzy or faint before, during, or after a shot?
Do you have allergies to medication, food, a vaccine component, or latex?
Have you had a seizure or a brain or other nervous system problem?
Have you 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?
Have you received any vaccinations in the past 4 weeks?

If you answered "yes" to any of the questions above, please explain here:
Has the resident ever had a serious allergic reaction to any of the following vaccine components: gelatin, yeast, neomycin, streptomycin, polymixin B, polysorbate 80, polyethylene glycol (PEG)?
Potential Serious Vaccine Allergy Alert:

You have indicated that you are allergic to a common vaccine component that may be a contraindication or precaution to getting certain vaccines. For your safety, please call the pharmacy and speak with a pharmacist for more information about specific vaccine allergen components, if the vaccine you're looking for would be safe to receive, and your next steps. Thank you for working with us to help keep our patients safe!

Clinic Phone Line: 512-623-2050
Emergency Contact Name:

First NameLast Name
Emergency Contact Phone Number:
Please enter a valid phone number.Format: (000) 000-0000.
Relationship
Acknowledgement, Consent, and Signature
Signatures and Consent

By signing below, I consent for Kannon Health to administer the vaccine(s) I have requested under a Texas-authorized standing order. I certify that:
- I am the patient and at least 18 years old; or
- I am the parent or legal guardian of the minor patient; or
- I am otherwise authorized under Texas law or court order to consent for the patient; or
- The authorized person is unavailable, and I have authority under Texas law as a grandparent, adult sibling, adult aunt/uncle, stepparent, or another adult with actual care, control, and written authorization for the child. I confirm I know of no refusals or withdrawals of consent for this child.
HIPAA and Use of Information
I acknowledge that I received or was offered Kannon Health’s HIPAA Notice of Privacy Practices and consent to the use and disclosure of my Protected Health Information (PHI) as described in that Notice.

I consent to Kannon Health reporting my immunizations to the Texas State Immunization Registry (ImmTrac). I understand authorized providers, agencies, and certain payers may access this information.

I authorize Kannon Health to:
- release medical or billing information to healthcare providers, Medicare, Medicaid, or payers as needed for care or payment;
- submit claims for services I receive;
- receive payment of authorized benefits on my behalf;
- notify the partnering facility, employer, or organization that I received the selected vaccine(s), with no additional information shared.
I understand insurance coverage is not guaranteed and I agree to pay any amount not covered by my insurance or benefits.

Not a Substitute for a Primary Physician
- I understand Kannon Health representatives are not my personal physician and do not diagnose or treat medical conditions. Receiving a vaccine does not create a doctor–patient relationship. I agree to seek medical care from a physician if I need medical advice or have concerns.
Risks, Observation, and Emergency Response
- I understand that vaccines, including new or updated vaccines, can have side effects or rare complications. I have had the chance to ask questions and all questions were answered to my satisfaction.
- I agree to remain near the vaccination area for at least 15 minutes for observation.
- If I have a reaction or medical event, I consent to Kannon Health calling 911 or emergency medical services, and I understand I am responsible for any related costs.
- If a Kannon Health staff member is exposed to my blood or body fluids, I agree to review and sign the “Kannon Health Post-Exposure Consent for Testing” form.
- I agree to seek medical attention right away if I experience concerning symptoms after I leave. I understand Kannon Health is not responsible for complications that happen after I leave or if I do not follow medical advice.
Release, Indemnity, and Legal Protections
- To the fullest extent permitted by Texas law, I, on behalf of myself, my heirs, and personal representatives, waive, release, indemnify, defend, and hold harmless Kannon Health, its staff, employees, agents, independent contractors, and affiliates from any and all claims or liabilities related to the administration of vaccine(s) or related services.
- I understand that some services may be provided by independent contractors and, to the extent permitted by Texas law, Kannon Health is not liable for their actions or omissions.
- I understand that Kannon Health makes no warranty or guarantee, expressed or implied, regarding results or outcomes of the vaccine(s) administered.
  To the extent permitted by Texas law, Kannon Health’s liability for any claim will not exceed the amount paid for the service.
- This consent will be governed solely by the laws of the State of Texas. Any dispute must be handled only in a court located within the State of Texas.
- If any part of this consent is found invalid, the rest will remain fully effective.
- I agree that my electronic signature has the same force and effect as a handwritten signature under Texas law.
- Kannon Health has provided information about the risks and benefits of the COVID-19 vaccine and has given me the chance to ask questions.
- My choice to receive this vaccine is based on either: (a) a health condition or risk factor that makes vaccination recommended for me, or (b) my own decision after reviewing information and discussing the vaccine with a Kannon Health provider.
- I release and hold harmless Kannon Health, its pharmacists, staff, the ordering pharmacist, and the supervising physician from liability connected to my choice to receive this vaccine when provided in line with FDA labeling and accepted immunization guidelines.
Final Acknowledgments

By signing below, I confirm that:
- The information I provided is accurate.
- I voluntarily request the vaccine(s) listed on this form.
- I understand I must schedule a new appointment if I miss my visit.
- I will arrive on time.
- I have been provided the current CDC Vaccine Information Statements (VIS).
- I have been provided the current DSHS Vaccine Information Sheet for COVID vaccines
- I have been provided with this list of vaccine components, contraindications, and precautions.
- I have been provided with information about the CDC's V-safe After Vaccination Health Checker
- I have been provided information on how to report an adverse reaction to a vaccine through VAERS.
Who is completing this vaccination registration form?
If the individual receiving the vaccine is unable to provide their own medical consent (for example due to age, cognitive impairment, or other legal circumstance), please provide the information of the person authorized to consent on their behalf.
Full Name of Authorized Entity *
Email*

Phone Number
Signature of patient or authorized person for consent
Date of Form Completion:

MonthDayYear
Date
Comments, Notes, or Questions for Kannon Health
1 Day after Appointment

MonthDayYear
Date
Should be Empty:

Rows	Yes	No	Don't Know
Are you currently pregnant?
Are you currently breastfeeding?

Vaccine Clinic Registration and Consent

Appointment Scheduling

Click "Next" to Choose Vaccines

Vaccine Selection

Attendee Demographic Information Continued

Health Insurance Coverage

Medicare Part B Insurance Information

Medical Insurance Information

Medicaid Information

Attendee Medical History

Acknowledgement, Consent, and Signature