Who is eligible to receive a vaccine?
   ★ Students without healthcare insurance - Students who do not have insurance coverage are to pay $15.00 per vaccine. Cash and electronic payment through PayPal is accepted.
   ★ Students with healthcare insurance - Insurance claims for immunizations will be submitted for those who provide proof during registration and onsite. Copies of insurance cards will be scanned on the day of the clinic. The following plans are accepted:
      ☆ Aetna PPO
      ☆ BlueCross BlueShield Illinois PPO
      ☆ Cigna PPO
      ☆ Humana PPO
      ☆ Medicaid
      ☆ United Healthcare PPO

Do I need to register ahead of time?
Yes, please provide the necessary demographic and medical information below. Each student needs their own appointment/registration. If you do not have insurance, you must select Not Insured (Electronically Pay $15.00).

Does my student need to have to receive a vaccine?
   1. Appointment Time (REQUIRED)
   2. Copy of insurance card (REQUIRED)
   3. Dress appropriately to receive an injection in the upper arm.

Required School Immunizations by Grade/Age:
   Children entering Pre-K typically receive the following vaccines:
      Dtap Dose 4
      MMR
      Polio
      Pneumococcal
      Varicella
   Students, ages 11+ typically receive the following vaccines:
      TDaP
      Meningitis

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 your school's coordinator.
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
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
Are you taking salicylate medication such as aspirin? Yes No
Have you had a blood transfusion or received other blood products recently? Yes No
Do you have tuberculosis? Yes No
Have you ever had an anaphylactic reaction to polymyxin B, or streptomycin? Yes No
Are you allergic to aluminum and aluminum hydroxide? Yes No
Terms & Conditions
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.




Need help? Contact us at jelverman@zion6.org


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