COVID Vaccination Registration & Consent Form

COVID-19 Vaccine Registration and Consent Form*

Please fill out the form below so your visit will be as quick as possible!

Please check with the location for appointments or walk-ins!

THIS FORM IS FOR ADULT DOSES ONLY

Hi! Thank you for your interest in receiving the COVID-19 vaccination. Please complete this form to pre-register for the COVID-19 Vaccination.

We will contact those eligible according to relevant state guidelines and pre-registered by email to book appointments as they become available. Appointments for the COVID-19 vaccine will be on a first come, first served basis to those eligible. Due to the limited availability, please note that pre-registering does not guarantee an appointment.

What location would you like to get a COVID Vaccine From*

(PLEASE NOTE WE ONLY HAVE MODERNA AS OF NOW) I would like to receive a:

First/Second Dose ShotBooster Shot

I previously received:

Jannsen (J&J)Pfizer BiontechModerna

My last shot was:

Date

Did you receive your first or second dose from us?

YesNo

Has any of your information or insurance information changed since your last visit with us?

YesNo

Patient Information

Recipient Name*

First NameLast Name

Preferred Name

Date of Birth*

Date

Address*

Street Address

Street Address Line 2

CityState

Zip Code

Email Address*

example@example.com

Phone*

Phone Opt-In

This a mobile PhonePlease text me! (Standard msg and data rates may apply)

Preferred Language*

Insurance Information

Do you have insurance?*

YesNo

Please Take a Photo of the Front and Back of your Prescription Insurance Card. Prescription Insurance Card should include RX BIN, RX PCN, RX GRP, and ID.

For those with Medicare, please provide your Medicare Medical Benefits info (the white paper-like card with red and blue)

For those unable to upload a picture, there is a file upload option at the bottom of the form. You should also bring your card with you to your appointment.

Front of Prescription (Rx) Insurance Card

Back of Prescription (Rx) Insurance Card

Primary Card Holder

Relation to Patient

Insurance Company Name

Primary Insurance ID#

RX BIN

RX Group

RX PCN

Do you have secondary insurance?

YesNo

Primary Card Holder

Secondary Insurance ID#

Secondary Insurance Group #

If uninsured, check the box below to attest that the following information is true and accurate:

I do not have any insurance, including but not limited to Medicare, Medicaid or any other private or government funded health benefit plan. In order to have your vaccine administration fee paid for by the United States Health Resources & Services Administration's COVID-19 Program, please provide either (a)valid Social Security number, (b)state identification number and state of issuance, OR (c) a driver’s license number and state of issuance.

Social Security Number

Just numbers, no dashes

or State ID # & State

or Driver license # & State

Appointment Booking

For appointments, please:

Select a date from the calendar below
Select a time
Click the blue "Confirm" button
Complete the booking questions
Click Schedule Event
Confirm your Eligibility and Consent below the appointment field
Click Submit at the bottom of this form

Notes: It is very important to make sure that you click the orange Submit button at the bottom of the form so we receive your information and make for a quick and easy appointment.

To ensure our supply is enough for everyone on a given day, please separate appointments for different individuals.

Thank you!

For Booster Shots in Elmsford - Please select an appointment from below and click .

For vaccinations in Garfield - Please select an appointment from below and click .

Eligibility & Consent

I confirm that I am eligible to receive the COVID-19 vaccination based on my applicable current state guidelines:

Confirm

Emergency Use Authorization

The FDA has made the COVID-19 vaccine available under an emergency use authorization (EUA). The EUA is used when circumstances exist to justify the emergency use of drugs and biological products during an emergency, such as the COVID-19 pandemic. This vaccine has not undergone the same type of review as an FDA-approved or cleared product. However, the FDA’s decision to make the vaccine available is based on the totality of scientific evidence available, showing that known and potential benefits of the vaccine outweigh the known and potential risks. Please note: FDA approved the Pfizer-BioNTech COVID-19 vaccine as a two-dose series in individuals 16 years of age and older. The vaccine continues to be available under an EUA for certain populations, including for those individuals 12 through 15 years of age and for the administration of a third dose in the populations set forth in the consent section below.

Consent

I have read, or had explained to me, the information sheet about the COVID-19 vaccination. I understand that if my vaccine requirestwo doses, I will need to be administered (given) two doses to be considered fully vaccinated. Further, I understand that a third dose of my vaccine (“booster”) may be recommended for me to receive at least 6 months following the second dose of Pfizer-BioNTech COVID-19 vaccine if I am a member of a certain population (e.g., 65 years or older, a resident of a long term care facility, 50-64 years with an underlying medical condition, 18-49 years with an underlying medical condition based on individual benefits and risks, 18-64 years and at an increased risk for COVID-19 exposure and transmission because of occupational or institutional setting based on individual benefits and risks) to increase my protection.

I have had a chance to ask questions which were answeredto my satisfaction (and ensured the person named above for whom I am authorized to provide surrogate consent was also given a chance to ask questions). I understand the benefits and risks of the vaccination as described.

I request that the COVID-19 vaccination be given to me (or the person named above for whom I am authorized to make this request and provide surrogate consent). I understand there will be no cost to me for this vaccine. I understand that any monies or benefits for administering the vaccine will be assigned and transferred to the vaccinating provider, including benefits/monies from my health plan, Medicare or other third parties who are financially responsible for my medical care. I authorize release of all information needed (including but not limited to medical records, copies of claims and itemized bills) to verify payment and as needed for other public health purposes, including reporting to applicable vaccine registries.

Recipient / Surrogate / Guardian Name*

First NameLast Name

Relationship to patient, if other than recipient

Date*

Date

Hour MinutesAM/PM Option

Recipient / Surrogate / Guardian Signature*