WE WILL BE USING AN ELECTRONIC CONSENT SYSTEM FOR REGISTRATION SO PRINTING YOUR CONSENT FORM IS OPTIONAL

There is no out of pocket cost for this vaccination. Your answers to the medical history questions below will be reviewed for accuracy at time of service.

Your Medicare number is required for billing purposes. Please note that a confirmation email will be sent to the email address provided. Your Medicare ID will be partially redacted in that email.

For State of Vermont clinic dates, directions and FAQ, please click here.
Location Filter
First Name
Last Name
Date of Birth
 
 
Email for Registration Confirmation
Confirm Email for Registration Confirmation
Phone Number
Gender
Relationship to Company
Employee ID # for SOV Actives/Temps Only
Insurance Billing Information
Insurance Provider
 
Services I'd like to receive
You will receive those immunizations as medically indicated by your health consultant staff. Vaccine Information Statements are available online here.
Medical History Questions
Have you ever had an anaphylactic or severe allergy reaction to any of the vaccines or any component of a vaccine that you are choosing to receive today? Yes No
Have you ever had an anaphylactic reaction, such as hives, wheezing, difficulty breathing or circulatory collapse related to latex, chicken eggs, egg products, gelatin, neomycin, yeast, or thimerosal, which is found as a preservative in contact lens solution and some vaccines? Yes No
Do you have any history of Guillain-Barre Syndrome? Yes No
Have you ever been dizzy or faint when getting a vaccine or having your blood drawn? Yes No
Are you immunocompromised or taking medications that may cause you to have a decreased immune response to the vaccine? Yes No
Are you pregnant, trying to get pregnant, or breastfeeding? Yes No



Need help? Contact us at accounts@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.