Gavin School District 37 & Fox Lake Grade School District 114 students are eligible to participate. Please refer to the INSTRUCTIONS distributed by your school district or click here. If you need to update an address or insurance information after you register, you can only do so on the day of your appointment. You are unable to go back and edit your appointment unless you completely cancel. You are able to cancel your appointment through your confirmation email. If you have not received a confirmation email, please check your spam before you contact your school district.
Clinic Location
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
Ethnicity
Race
Emergency Contact Information
Name
Relationship
Phone
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? As some of these vaccines have not been tested in pregnancy or while breastfeeding, they should only be administered if the benefits outweigh the risks. It is recommended to wait at least 30 days after vaccination to try and get pregnant. Yes No
Have you had other live vaccines (MMR, Yellow Fever, Varicella) or a TB test in the past 4 weeks? Yes No
Have you received passive antibody therapy as treatment for COVID-19 in the past 90 days? Yes No
Do you have a bleeding disorder or are you taking a blood thinner? Yes No
Do you have a progressive neurological disorder, uncontrolled epilepsy or progressive encephalopathy? Yes No
Did you ever develop encephalopathy (brain disorder) without an identifiable cause within 7 days of administration of prior DTP, DTaP or Tdap? Yes No
Do you have polycythemia vera (rare blood disorder) or Leber’s disease (rare eye disorder) or ever had an allergic reaction to hydroxocobalamin or cyanocobalamin? Yes No
Have you received any previous pneumonia vaccinations? Yes No
Have you had a serious reaction to a previous dose of PPV (Pneumococcal Polysaccharide Vaccine) or any component of the vaccine, including a vaccine containing diphtheria toxoid? Yes No
Terms & Conditions
I certify that I am: (a) the patient and at least 18 years of age; (b) the parent or legal guardian of the patient and confirm that the patient is at least 5 years of age; or (c) authorized to consent for vaccination for the patient named above and (d) attest that I am in an Illinois COVID Vaccination phase that has been allowed by the State Public Health Department to receive COVID-19 vaccination. Further, I hereby give my consent to Passport Health or Preventive Health Partners or the Illinois Departments of Public Health or their agents to administer the COVID-19 vaccine to the patient named above. I understand that this product has not been approved or licensed by the FDA, but has been authorized for emergency use by the FDA under an EUA to prevent Coronavirus Disease 2019 (COVID-19) for use in individuals 5 years of age and older; and the emergency use of this product is only authorized for the duration of the declaration that circumstances exist justifying the authorization of emergency use of the medical product under Section 564(b)(1) of the FD&C Act unless the declaration is terminated or authorization revoked sooner. I understand that this document provides consent for receipt of the complete vaccine series, should a vaccine require more than one shot to complete the series. I understand that it is not possible to predict all possible side effects or complications associated with receiving COVID-19 vaccines. I have read or had explained to me information provided about the vaccine that I, or my child (if applicable), is going to receive. I have had the chance to ask questions that were answered to my satisfaction and I understand the risks and benefits of vaccination and I voluntarily assume full responsibility for any reactions that may result. I have been provided with access to the Vaccine Information Sheet (VIS) or Emergency Use Authorization Fact Sheet on the COVID-19 vaccine I, or my child (if applicable) have elected to receive. I acknowledge that I, or my child (if applicable) have been advised to remain in the vaccination location for 15-30 minutes after vaccine administration for observation for any potential adverse reactions. If I, or my child (if applicable) experiences a severe reaction, I will call 9-1-1 and my doctor or go to the nearest hospital emergency room. I further consent to any emergency treatment or emergency hospital transportation required to care for any vaccine reaction that may occur at the vaccination location for myself or my child (if applicable) including administration of the medication Epinephrine which is used for severe allergic reactions. On behalf of myself, my child (if applicable), my heirs and personal representatives, I hereby release and hold harmless Passport Health, Preventive Health Partners, the State of Illinois, the Illinois Department of Public Health, the School District I, or my child (if applicable), attends and its Board of Education and their staff, agents, successors, divisions, affiliates, subsidiaries, officers, directors, contractors and employees from any and all liabilities or claims whether known or unknown arising out of, in connection with, or in any way related to the administration of the vaccine listed above on the patient listed above.




Need help? Contact us at info@gavin37.org


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.