I consent to using the above submitted information to register, and I understand the form submission is HIPAA protected.
I understand that the vaccination schedule depends on availability and national priority. I also understand that this online registration for the purose of organizing contactless vaccination. Furthermore, the registration is not a guarantee for a vaccination on my own schedule, and I can choose any other physician to get vaccination after this registration. The clinic will contact me for the time and date of vaccination scheduling and may need to make a telehealth and/or require an in-person visit.
I understand that the vaccination is a ongoing processes, and many types of vaccines are in the making and waiting for FDA Emerency Use Authorization. I acknowledge that the presented vaccine, may vary in its properties, such as duration of protection from infection, percentage of effectiveness or efficacy, or even unknown long term side effects.
The information provided above is true to the best of my knowledge. I agree to pay for COVID-19 services through one of the following: (1) I authorize Pacific Horizon Medical Center to bill my insurance for the services provided.(2) I don’t have medical insurance, and cannot afford to pay. The clinic will bill the government COVID-19 program for the services provided to me (including vaccination and/or telemedicine or per office visit). (3) I choose to pay by cash.
I also understand that due to each insurance's regulations and limitations, the clinic may not be able to take certain insurances. Therefore, I understand that the clinic reserves their choice to schedule only patients contracted insurance. In such cases, I understand that I am recommended to find another service.
By checking the box below and adding my signature, I guarantee that I have read and accepted the above information.