COVID-19 Vaccine Request Form
Name
*
First Name
Last Name
Birth Date
*
-
Month
-
Day
Year
Date
Gender
Female
Male
Phone Number
*
Please enter a valid phone number.
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Insurance Company
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
Back
Next
Are you HOMEBOUND?
Yes
No
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?
Yes
No
If yes, please provide month/year of diagnosis
MM-YYYY
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.
Register
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