Temple Beth El Vaccine Clinic

Patient Information and Consent Form
You are currently registering for an upcoming vaccine clinic at Temple Beth El.

Please plan to arrive any time during this time block, first come first served.

This form will take 2-5 minutes to complete.
Please select the date you will attend the clinic
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
2 digit month, 2 digit day, 4 digit year
Date of Birth

MonthDayYear
2 digit month, 2 digit day, 4 digit year
Current Age
Gender
Ethnicity
Insurance Information
Please upload a photo of the front of your insurance card.
File Upload

Cancelof
I know my Medicare Number.
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
Are you sick or do you currently have a fever?
Do you have a known allergy to any components of the vaccine, for example, eggs, polyethylene glycol (PEG), polysorbate, a previous injection of any kind?
Do you have a history of immune-mediated syndromes such as thrombosis, thrombocytopenia, or heparin-induced thrombocytopenia?
Do you have a history of myocarditis or pericarditis?
Do you have a weakened immune system (i.e., HIV infection, cancer, organ transplant, DiGeorge Syndrome or Wiskott-Aldrich Syndrome) or take immunosuppressive drugs/therapies, (high dose corticosteroids, CAR-T-cell therapy, hematopoietic cell transplant HCT)?
Consent for Vaccination
I hereby give my consent to receive vaccines for (check all that apply):
I understand the potential risks and benefits of the vaccine(s) I have given my consent to receive above as summarized at the CDC website: https://www.cdc.gov/vaccines/hcp/current-vis/index.html
I understand that as required by state law, all immunizations will be reported to the Department of Public Health Massachusetts Immunization Information System (MIIS). I can access the MIIS Fact Sheet for Parents and Patients at www.mass.gov/dph/miis
I give permission for Union Pharmacy to bill my healthcare insurance company for the costs of administering the vaccine.
I understand that I am ultimately responsible for any charges that are not covered by my insurance plan.
I have reviewed this entire Patient Information and Consent Form and hereby certify it is true and correct to the best of my knowledge.
Patient Signature
Name of Parent/Guardian

First NameLast Name
Parent/Guardian Signature
Please verify that you are human
Should be Empty:

Patient Information and Consent Form

Patient Information

Insurance Information

Screening Questionnaire

Consent for Vaccination