COVID Safe AZ
Complete the form below to register to receive the FIRST DOSE of the COVID vaccination.
If you have Medicare, please select the Medicare option and use your primary medicare ID.
Masks will be required.
Valid photo ID will be required.
For appointments on or after February 15th, you must be at least 65 years of age to register
OR
Phase 1A with valid proof (required at check-in).
For appointments on February 11th & 12th, you must be at least 75 years of age to register
OR
Phase 1A with valid proof (required at check-in).
Clinic Location
-- Select a Location --
Date
-- Select Date --
Time
-- Select Time --
First Name
Last Name
Date of Birth
-- Month --
01 - January
02 - February
03 - March
04 - April
05 - May
06 - June
07 - July
08 - August
09 - September
10 - October
11 - November
12 - December
-- Day --
01
02
03
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29
30
31
-- Year --
2021
2020
2019
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2015
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2012
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1902
1901
1900
Email
Confirm Email
Phone Number
Gender
-- Select --
Male
Female
Decline to Answer
Address
City
State
-- Select --
AL - Alabama
AK - Alaska
AZ - Arizona
AR - Arkansas
CA - California
CO - Colorado
CT - Connecticut
DC - District of Columbia
DE - Delaware
FL - Florida
GA - Georgia
HI - Hawaii
ID - Idaho
IL - Illinois
IN - Indiana
IA - Iowa
KS - Kansas
KY - Kentucky
LA - Louisiana
ME - Maine
MD - Maryland
MA - Massachusetts
MI - Michigan
MN - Minnesota
MS - Mississippi
MO - Missouri
MT - Montana
NE - Nebraska
NV - Nevada
NH - New Hampshire
NJ - New Jersey
NM - New Mexico
NY - New York
NC - North Carolina
ND - North Dakota
OH - Ohio
OK - Oklahoma
OR - Oregon
PA - Pennsylvania
RI - Rhode Island
SC - South Carolina
SD - South Dakota
TN - Tennessee
TX - Texas
UT - Utah
VT - Vermont
VA - Virginia
WA - Washington
WV - West Virginia
WI - Wisconsin
WY - Wyoming
Zip
Occupation
-- Select --
Medical Professional
Educator
First Responder
None of the Above
Ethnicity
-- Select --
Hispanic or Latino
Not Hispanic or Latino
Unknown Ethnicity
Race
-- Select --
American Indian or Alaska Native
Asian
Native Hawaiian or Other Pacific Islander
Black or African American
White
Other
Unknown
Insurance Billing Information
Insurance Provider
-- Select --
Medicare
Medicaid
Other
None
Provider Name
Medicare ID
Member ID
Group ID
Insured through
Self
Spouse / Domestic Partner
Parent
Other
Name
Address
DOB
Services I'd like to receive
COVID-19 Vaccine
Medical History Questions
Do you have a fever (>100), infection or current illness today?
Yes
No
Have you ever had a significant allergic reaction to a vaccine or other injection?
Yes
No
Are you pregnant, plan to be pregnant or currently breastfeeding?
Yes
No
Have you received passive antibody therapy as treatment for COVID-19?
Yes
No
Do you have a severely immunocompromising condition?
Yes
No
Do you have a bleeding disorder or are you taking a blood thinner?
Yes
No
Do you have an allergy to a component of the vaccine?
Yes
No
Have you received another vaccine in the last 14 days?
Yes
No
Based on your medical history, a nurse consultation will be provided at your scheduled appointment to further evaluate whether you are a candidate for some or all of the selected service(s).
Please note that the outcome of that consultation may result in not receiving the service(s).
Terms & Conditions
I give my consent for the services that I am requesting from Passport Health and its entities/contractors. I acknowledge that I received the Vaccine Manufacturer COVID-19 Fact Sheet for Recipients and Caregivers prior to receiving the vaccine and have had the opportunity to ask questions. I understand the benefits and risks of the vaccine and request it be administered to me or the person for whom I am authorized to make consent. I may request the Notice of Health Information Practices (HIPAA) and I authorize my immunization record to be recorded with the State Vaccine Registry and released to employer, school, and/or physician if requested.
Information from Moderna regarding the COVID vaccine can be found
here
.
I agree to the terms and conditions indicated above.
Submit
Need help? Contact us at
covidsafeaz@passporthealthusa.com
Passport Health is committed to keeping your personal data safe and we endeavor to take every reasonable precaution to ensure security. Passport Health complies with health care data reporting requirements of State and Federal authorities, as well as subpoenas, and may use or disclose data as required or requested for billing and payment purposes. Outside of this, access to your personal information is restricted to employees at Passport Health for internal purposes only and is never sold.
I consent to receiving immunizations from Passport Health. I have been given an opportunity to review the Vaccine Information Statements located
here
. At the time of my appointment I will be made aware of certain risks that may be associated with the vaccine(s) including the potential for allergic reaction and I will be offered the opportunity to ask questions and I believe that the benefits outweigh the risks. I assume full responsibility for any reactions that may result. I authorize Passport Health to disclose my health information to my state immunization registry, my physician, my employer and my insurance company. I authorize Passport Health to notify me of future health events, services or products. I hereby acknowledge receipt of Passport Health's
Notice of Privacy Practices
. If I am signing this consent on behalf of another individual, I hereby certify that I have the legal right to do so as the person's parent or legal guardian, pursuant to a health care power of attorney, pursuant to a court order, or pursuant to some other legal right to consent to health care for the individual. I agree that the insurer or payer listed above is my primary medical coverage and that I am responsible for payment if services are not covered for any reason or are subject to any co-pays, deductibles, coinsurance or prior authorizations.