The Covid 19 vaccine administered at this clinic will be Novavax. Adults and children ages 12 and up are eligible to receive Novavax regardless of previous Covid 19 vaccines received or no Covid 19 vaccine history. I acknowledge that, in order to facilitate the billing of insurers, Passport Health may need to share certain, limited portions of my Treatment Records, including the data collected by Passport Health, with third parties and my employer, Tulane University. Because the act of sharing this information may eliminate certain protections, Passport Health will voluntary apply federal HIPAA regulations for the privacy of Protected Health Information to such shared Treatment Records. I further acknowledge that Passport Health is authorized to use and disclose my Confidential Health Information for treatment, payment, and health care operations, to the full extent permitted by and in compliance with the HIPAA Privacy and Security Rule’s governing Protected Health Information. I authorize Passport Health and/or its designees to disclose all or part of my medical or billing records to any insurance carrier or persons employed by such carrier for the purpose of collecting insurance benefits and auditing claims. I further acknowledge that Passport Health may utilize the services of a third party Business Associate or affiliated entity for medical account billing and servicing. I hereby indemnify and release Tulane University and Passport Health from any and all responsibility relative to the release of such information. Passport Health will enter all immunization records into LINKS as required by Louisiana state law.
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
Tulane Employee Badge Number
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



Need help? Contact us at michele@passporthealthlouisiana.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.