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
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
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, 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




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.