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
First Name
Last Name
Date of Birth
 
 
Email
Confirm Email
Phone Number
Gender
Occupation
Ethnicity
Race
Insurance Billing Information
Insurance Provider
 
Services I'd like to receive
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
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.




Need help? Contact us at covidsafeaz@passporthealthusa.com