Immunize El Paso COVID-19 Vaccine Appointment

COVID-19 Vaccination Program

Immunization Consent and Appointment System

COVID-19 Vaccine for Ages 6 Months and Older Now Available!

Free to anyone 6 Months of age and older.

Pfizer booster doses for 5 years of age and older.

Moderna booster doses for 18 years of age and older.

INITIAL, SECOND, THIRD, AND BOOSTER* DOSES

Please have your ID and health insurance information on hand (if applicable), you will be asked to provide this information during registration.

If you experience difficulties, please contact 915-533-3414 (Mon-Fri 8A-5P)

Select Location & Time

Begin your appointment selection by choosing the District location you'd like to visit.
Attention: To schedule a COVID-19 appointment at our Immunize El Paso Clinics please click here: HERE

For school-based vaccine clinics, please continue with this form.
Please Select Your Child's School District *
Socorro ISD Locations*
Idea Schools*
Clint ISD Locations*

Patient Registration
All Children under the age of 18 MUST be accompanied by an adult.
Patient Name*

First NameMiddle NameLast Name
Patient Date of Birth*

MonthDayYear
Date
Gender*
Patient Social Security Number*
Address*

Street Address

Street Address Line 2

CityState

Zip Code
Phone Number*

Area CodePhone Number
Personal email address*

Confirmation Emailexample@example.com
Race*
Please describe your ethnicity*

Health Insurance Information

There will be no cost to you for the COVID-19 vaccine. If you are insured, we ask for insurance information so Immunize El Paso can be reimbursed for the admiinistration of the vaccine through your insurance company.
Health insurance?*
Heath Insurance Carrier Name (Blue Cross, Medicare, Medicaid, etc.)*
Member ID Number*
Group Number*
To whom is this policy issued:*
Policy Holder Name*

First NameLast Name
Policy Holder SSN*
Photo of insurance card - FRONT*

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Photo of insurance card - BACK*

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If you do not have insurance, we will seek reimbursement through the Health Resources and Services Administration (HRSA) Non-Insured Program which requires us to obtain a Social Security or Driver’s License number for verification. I attest that to the best of the my knowledge at the time of this submission that I am uninsured, meaning that I do not have healthcare coverage whatsoever.

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If you do not have insurance, we will seek reimbursement through the Health Resources and Services Administration (HRSA) Non-Insured Program which requires us to obtain a Social Security or Driver’s License number for verification. I attest that to the best of the my knowledge at the time of this submission that I am uninsured, meaning that I do not have healthcare coverage whatsoever.

COVID-19 Vaccination Informed Consent
I have received, read, and understand the COVID-19 Vaccine Information provided by ProAction, Inc. I hereby authorize ProAction, Inc. and the practitioners employed by or contracted with ProAction, Inc. (each, a “Provider”) to administer the Vaccine I have requested above as a two-dose regimen series administered in accordance with manufacturer and CDC recommendations (the “Services”). The scope of this consent includes discussion about the vaccine(s) and its administration between ProAction, Inc., and other health care professionals for purposes of care and treatment. I understand that I may withdraw this consent at any time by making a request in writing.

I acknowledge that I have been informed about, the following:

• The goal of the Services is to administer the Vaccine I requested.

• The Provider(s) will provide me with additional information about any risks associated with the Services, which depend upon my specific diagnoses and health status.

• Administering Vaccines is not an exact science and there are no guarantees as to the results of the Services that may be provided to me.

• The nature and purpose of the Services, expected benefits, potential known and unknown complications, the likelihood of achieving goals, and relative risks that may arise from the Services, along with the relevant risks and consequences of no treatment.

I understand the benefits and risks of the Vaccine and I expressly consent, request, and authorize the administration of the Vaccine. On behalf of myself, my heirs, and personal representatives, I hereby release and hold harmless Pro-Action, Inc, each Provider, and the applicable staff, agents, successors, divisions, affiliates, subsidiaries, officers, directors, contractors, and employees from any and all liability or claims, whether known or unknown, arising out of, in connection with, or in any way related to the Services. I acknowledge that: (a) I understand the purposes/benefits of my state’s vaccination registration (“State Registry”) and my state’s health information exchange (“State HIE”); and (b) the Provider may disclose my vaccination information to the State Registry, to the State HIE, or through the State HIE to the State Registry, for purposes of public health reporting, or to my healthcare providers enrolled in the State Registry and/or State HIE for purposes of care coordination.

I further authorize the applicable Provider to (a) release my medical or other information, including my communicable disease (including HIV), mental health and drug/alcohol abuse information, to, or through, the State HIE to my healthcare professionals, Medicare, Medicaid, or other third-party payers as necessary to effectuate care or payment; (b) submit a claim to my insurer for the Services, and (c) request payment or authorized benefits be made on my behalf to the applicable Provider with respect to the Services. I acknowledge that depending upon my state’s law, I may prevent, by using a state-approved opt-out form or, as permitted by my state law, an opt-out form (“Opt-Out Form”) furnished by the Provider: (a) the disclosure of my vaccination information by the Provider to the State HIE and/or State Registry; or (b) the State HIE and/or State Registry from sharing my vaccination information with any of my other healthcare providers enrolled in the State Registry and/or State HIE. The Provider will, if my state permits, provide me with an Opt-Out Form.

I understand that I may need to consent, depending on my state’s law, and to the extent so required, I hereby do consent by signing below to the Provider reporting my vaccination information to the State HIE, or through the State HIE and/or State Registry to the entities and for the purposes described in this Informed Consent Form. Unless I provide the Provider with a signed Opt-Out Form, I understand that my consent will remain in effect until I withdraw my permission and that I may withdraw my consent by providing a completed Opt-Out Form to the Provider and/or my State HIE, as applicable. I understand that even if I do not consent or if I withdraw my consent, my state’s laws may permit certain disclosures of my vaccination information to or through the State HIE as required or permitted by law. Photocopies/electronic transmissions/faxes of this consent and any signatures are to be considered as valid originals.

MY SIGNATURE BELOW INDICATES THAT I VOLUNTARILY AGREE TO ALL OF THE ABOVE AND THAT THE NATURE OF THIS CONSENT WAS EXPLAINED TO ME AND THAT I HAD THE OPPORTUNITY TO ASK ANY AND ALL QUESTIONS REGARDING THE ABOVE AND MY QUESTIONS HAVE BEEN ANSWERED TO MY SATISFACTION. I UNDERSTAND THE BENEFITS AND RISKS OF THE VACCINE AND I EXPRESSLY CONSENT, REQUEST, AND AUTHORIZE THE ADMINISTRATION OF THE VACCINE. I HAVE BEEN PROVIDED WITH THE CDC’S VACCINE INFORMATION SHEET(S) OR THE EMERGENCY USE AUTHORIZATION (EUA) PATIENT FACT SHEET CORRESPONDING TO THE VACCINE THAT I AM RECEIVING.
Signature

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If you will not be attending the COVID-19 vaccine clinic with your child / dependent, please upload a copy of the parent / guardian's state-issued photo identification card*

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Date of Service*

MonthDayYear
Date
COVID-19 Vaccine Administered*
Vaccine Dose*
Lot Number*
Route & Site*
Given by*
Place of Service*
Should be Empty:

	Yes	No
Is the person to be vaccinated currently under quarantine or isolation orders for COVID-19?
Do you or the person being vaccinated have any COVID-19 or influenza-like symptoms? (Fever, cough, loss of sense of smell or taste, breath, sore throat, runny nose or congestion, nausea or vomiting, diarrhea)
Has a physician or medical provider indicated that the person being vaccinated should NOT receive the COVID-19 vaccine?
Have you or the person bei ever had a serious reaction to a vaccine or a severe allergic reaction that required going to ER?

Screening Questionnaire for COVID-19 Vaccination

Select Location & Time

Patient Registration

Health Insurance Information

COVID-19 Vaccination Informed Consent