• COVID-19 VACCINE Scheduling and Consent form

    @ Westview Dental | 5429 California Ave SW | Seattle, WA | 98136
  • Welcome!
     
    Please read carefully and provide vaccine recipient information below.
     
     
    Review the following prior to your visit:
    CDC VACCINE INFO 
    https://www.cdc.gov/coronavirus/2019-ncov/vaccines

    Moderna Emergency Use Authorization(EUA): 
    https://www.modernatx.com/covid19vaccine-eua/eua-fact-sheet-recipients.pdf
  • WHICH *MODERNA* DOSE ARE YOU SCHEDULING? :
  • SCHEDULE YOUR VACCINE APPOINTMENT:
  • DATE OF BIRTH :*
     - -
    2 digit month, 2 digit day, 4 digit year

  • *The government must cover all persons who are eligible, regardless of home status or documentation! This will not affect your eligibility.

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  • The Washington DOH requires we collect and report using the below options.

    We recognize the below options are not representative of our community. (We welcome any and all individuals who are eligible for the vaccine, regardless of race, ethnicity, religious belief, sexual orientation, sex, gender identity, gender expression, ability, socioeconomic status, cultural orientation, national origin, and age.)

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  • COST of COVID-19 VACCINATION and ADMINISTRATION:

    YOU WILL NOT BE CHARGED FOR THIS VACCINATION. We may contact your insurance company related to administrative fees. It is illegal for your insurance (or us, for that matter) to charge you!

    FROM THE CDC

    Organizations and providers participating in the CDC COVID-19 Vaccination Program:
    • must administer COVID-19 Vaccine regardless of the vaccine recipient’s ability to pay COVID-19 Vaccine administration fees or coverage status
    • may seek appropriate reimbursement from a program or plan that covers COVID-19 Vaccine administration fees for the vaccine recipient
    • may not seek any reimbursement, including through balance billing, from the vaccine recipient

  • Vaccine availability has not been consistent, so our availability is subject to change. We want you to get scheduled as soon as possible.  This tool will regularly update with availability. 

  • Would you like to be contacted in the future for vaccination clinics and/or future health & wellness initiatives from our Nurse Practitioners? We will not spam you :)

  • By signing and dating below, I certify that (i) I am the individual completing the form; (ii) all information entered on this form is true and accurate to the best of my knowledge; including that I am eligible for the vaccine on date selected above based on Washington state guidelines (iii) I have been provided the fact sheet for the vaccine I am to receive and understand the risks and benefits; and (iv) By signing below, I consent to receive the COVID-19 vaccine.

  • DATE:*
     / /
    2 digit month, 2 digit day, 4 digit year
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