COVID-19 Vaccine Request Form
Please enter a valid phone number.
Street Address Line 2
State / Province
Postal / Zip Code
Or put N/A if no insurance - COVID vaccines are no cost to patient regardless of insurance status
Insurance ID (11 digit Medicare number if you have Medicare as seen below)
PLEASE INCLUDE YOUR 11 DIGIT MEDICARE NUMBER EVEN IF YOU HAVE A MEDICARE ADVANTAGE PLAN
Are you HOMEBOUND?
If HOMEBOUND, please describe your situation
Please indicate all health issues that are considered within the risk group
Have you been diagnosed with COVID-19?
If yes, please provide month/year of diagnosis
If you've had COVID-19, have you had an Antibody infusion? If so, when?
I hereby declare that all the given information is accurate.
Should be Empty: