Ability 360 Covid Vaccine Clinic
|
|
Complete the form below to register to receive the FIRST DOSE of the COVID vaccination.
Masks will be required. Valid photo ID will be required.
|
Clinic Location |
|
|
Date
|
|
|
Time
|
|
|
First Name |
|
|
Last Name |
|
|
Date of Birth
|
|
|
Parental/Guardian Consent
|
|
Please type your full name to electronically affirm consent as registrants parent/legal guardian.
Signature
|
|
Email
|
|
|
Confirm Email
|
|
Mobile Phone Number
|
|
|
Gender
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
Do you need an ADA reasonable accommodation?
|
|
|
Ethnicity
|
|
|
Race
|
|
|
Insurance Billing Information
|
Insurance Provider |
|
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 |
|
|
|
|
Terms & Conditions |
I, the undersigned, 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 to my satisfaction. I understand that there are risks and uncertainties inherent in vaccination, I waive and release any claims against Passport Health or its associated persons relating to or resulting therefrom, including any adverse reaction or other consequence of the vaccination, and I request it be administered to me or to the recipient, on whose behalf I am authorized to make this consent, waiver and release. 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 Pfizer regarding the COVID vaccine can be found here |
|
|