Pediatric COVID-19 Clinic Registration
|
|
Students, ages 5-11, 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 |
|
|
Date
|
|
|
Time
|
|
|
First Name |
|
|
Last Name |
|
|
Date of Birth
|
|
|
Email
|
|
|
Confirm Email
|
|
Mobile Phone Number
|
|
|
Gender
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
Ethnicity
|
|
|
Race
|
|
|
Emergency Contact Information |
Name |
|
|
Relationship |
|
|
Phone |
|
|
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 |
|
|
|
You will receive those immunizations as medically indicated by your health consultant staff. Vaccine Information Statements are available online here.
|
|
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. |
|
|