Eligibility & Payment
Only those with the following PPO insurance plans are eligible to participate and receive a vaccine: Aetna PPO, BlueCross BlueShield IL PPO, Cigna PPO, Humana PPO, and United Healthcare PPO.

Services
Flu and COVID-19 bivalent boosters are available at this clinic. COVID-19 bivalent boosters are available at this clinic for those 18 years+. You are eligible for a bivalent booster if it has been 2 months since the last dose of the primary series or your last booster. Pfizer and Moderna are the available COVID-19 bivalent vaccine manufacturers. Please select your preferred manufacturer when prompted to do so. For more information about COVID-19 boosters, click here.

Registration Process
1. Please provide demographic and medical information below.
2. Bring their PPO insurance card to be scanned onsite.
3. Bring your COVID-19 vaccine card if you plan on receiving a booster dose.
4. Dress appropriately to receive an injection in the upper arm.

You are able to cancel your appointment through your confirmation email. If you have not received a confirmation email, please check your email's spam folder before you contact Viktoria Rill at vrill@iit.edu.
Clinic Location
First Name
Last Name
Date of Birth
 
 
Email
Confirm Email
Mobile Phone Number
Gender
Which COVID-19 vaccine manufacturer do you prefer to receive?
Ethnicity
Race
Do you have PPO insurance? Only those who have PPO insurance plans are eligible to participate. Yes No
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 acknowledge I must have a PPO insurance plan to receive a vaccine at the onsite clinic. If I am insured, I acknowledge insurance claims will be submitted by Preventive Health Partners after the vaccines have been administered. I acknowledge I may need to clarify my insurance information with my employer or directly with Preventive Health Partners in the event it is entered wrong. If I do not have PPO insurance, I may be subject to paying out of pocket for the service I receive.




Need help? Contact us at vrill@iit.edu


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.