Complete the form below to register to receive the COVID vaccination or booster.

Masks will be required. Valid photo ID will be required.



Clinic Location
First Name
Last Name
Date of Birth
 
 
Email
Confirm Email
Gender
Ethnicity
Race
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
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




Need help? Contact us at accounts@passporthealthusa.com